THE - 

SELECT MEDICAL LIBRARY, 

AND 

ZStlttttt $outml of $&t#itiut. 



EDITED BY 

5J<fi>HIIESr IBHIIa^g MLuW* 

LECTURER ON THE INSTITUTES OF MEDICINE AND MEDICAL JURISPRUDENCE; 
MEMBER OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, 
AND OF THE AMER. PHILOS. SQC, ETC. 



A periodical publication so decidedly and obviously beneficial, to the profes- 
sion for whose use it is intended, as the Select Medical Library, and Eclectic Jour- 
nal of Medicine, needs little to be said of it in the way of explanation and eulogy. 

No argument is required to convince the members of a liberal profession, of 
the necessity, as a point of honour not less than of policy, of constantly adding 
to their store of knowledge, from the contributions of genius and experience in 
different ages and countries. The proposed plan will be found eminently con- 
ducive to this desirable object. By it, both the past and the present will be made 
to minister to the future; and a seasonable variety offered for every taste and 
exigency in medical reading. To the physician living in Missouri or Louisiana, 
monthly intelligence of all medical improvements, discoveries, and writings, and 
reprints of the best works, can be sent, through the medium of the Journal and 
Library, with nearly as much readiness, and at the same cost, as to his profes- 
sional brother living in any of the great cities on the seabord. The distant 
reader will receive this work by mail as he would his newspaper. 

In the Eclectic Journal, the history of cases which have a definite bearing and 
application, summaries of opinions and practice, criticisms brief and pertinent, 
will find a place. The circumstances which exert an influence over the health, 
both of individuals and of communities, shall receive a due share of notice ; it 
being as much the duty of the physician to foresee, and by timely warning to 
prevent, as, after its infliction, to cure disease. In the performance of this task, 
the more salient points will be presented, — the actual wants of the profession 
indicated, and all proper and practicable ameliorations, both scientific and 
ethical, suggested. 

There is reason to fear that the necessary union among the several departments 
of medicine, in order that they all shall be brought to bear upon those grand and 
paramount objects — the reliefer cure of bodily and mental suffering, and the pre- 
servation of health — is too much lost sight of. The causes of this aberration are not 
so easily indicated. They are, in part, attributable to the very accumulation of 
facts and phenomena, and to the minute subdivision of these into classes, for the 
purpose of aiding the memory, and of facilitating inquiry. Nor can an imme- 
diate cure be confidently promised. It is worth while, however, to make the 
effort; and it is intended that the contents of the Journal, and the works selected 
for publication in the Library, shall contribute to this good end. 



2 Catalogue of Works published in the Select Medical Librar 



The Editor of this work is in a situation and has that experience which give 
reasonable pledge of impartiality and readiness in the discharge of his duty. He 
is free from the trammels of party, is under no obligations to any medical 
government, corporation, or association as such, and has, withal, no personal 
grievance to complain of or to be redressed. He has had the editorial direc- 
tion, in former times, of Journals both Medical and Hygienic, in conjunction 
with able and enlightened friends, to whose kindness and counsel he may, he 
believes, look with confidence, in his present undertaking. His chief aim now, 
as it was then, is to elevate the character and increase the usefulness of that 
noble but illy requited profession of which he is ever proud to be a member. 



STANDARD WORKS 

PUBLISHED m 

®l)t Select 2*Tttrtcal atfitrarg, 

From NOVEMBER, 1836, to OCTOBER, 1837. 



1. LECTURES on the MORBID ANA- 
TOMY, NATURE, and TREAT- 
MENT of ACUTE and CHRONIC 
DISEASES. By the late John Arm- 
strong, M.D.; Author of "Practical 
Illustrations of Typhus and Scarlet 
Fever," &c. Edited by Joseph Rix, 
Member of the Royal College of Sur- 
geons. 690 pages of Library. 

The British and Foreign Medical Review 
says of this work : 

" We admire, in almost every page, the pre- 
cise and cautious practical directions; the strik- 
ing allusions to instructive cases; the urgent 
recommendations of the pupil to be careful, to 
be diligent in observation, to avoid hurry and 
heedlessness, to be attentive to the poor. Nothing 
can be more excellent than the rules laid down 
for all the parts of the delicate management of 
fever patients: nothing more judicious than the 
general instructions arising out of the lecturer's 
perfect knowledge of mankind His pru- 
dent admonitions respecting the employment of 
some of the heroic remedies, as mercury, arsenic, 
and colchicum, attest his powers of observation 
and his practical merits." " The pious office of 
preserving and publishing his Lectures has been 
performed by Mr Rix, with singular ability." 

2. OBSERVATIONS on the PRINCI- 
PAL MEDICAL INSTITUTIONS 
and PRACTICE of FRANCE, ITA- 
LY and GERMANY: with Notices of 
the Universities, and Cases from Hos- 
pital Practice: With an Appendix on 
ANIMAL MAGNETISM and HO- 
MOEOPATHY. By Edwin Lee, 
Member of the Royal College of Sur- 
geons, &c. 110 pages. 

" Mr. Lee has judiciously selected some clini- 
cal cases, illustrating the practice pursued at the 
different hospitals, and he lias wound up tlie vo- 
lume with an amusing account of animal mag- 



netism and homoeopathy— those precious effu- 
sions of German idealty, for which we refer to 
the work itself." — Medico- Chirurg. Rev. 

3. A THERAPEUTIC ARRANGE- 
MENT and SYLLABUS of MATE- 
RIA MEDIC A. By James Johnstone, 
M.D., Fellow of the College of Physi- 
cians, and Physician to the General 
Hospital, Birmingham. 72 pages. 

" This book cannot but be particularly useful 
to those who intend to lecture or write upon the 
Materia Medica; as well as to the students for 
whose particular use it is prepared." — Brit, and 
For. Med. Rev. 

4. A TREATISE ON TETANUS, being 
the ESSAY for which the Jacksonian 
Prize, for the year 1834, was awarded, 
by the Royal College of Surgeons in 
London. By Thomas Blizard Curl- 
ing, Assistant Surgeon to the London 
Hospital, &c. 130 pages. 

" This book should be in the library of every 
surgeon and physician. It is a valuable work of 
reference. It does not pretend to originality, for 
originality on such a subject was not wanted. 
But a compendium of facts was wanted, and such 
a compendium is this volume. We cannot part 
from Mr. Curling without thanking him for the 
information we have received in reading his 
work, and for the matter it has enabled us to 
offer to our readers." — Medico- Chir. Rev. 

5. PRACTICAL OBSERVATIONS on 
DISEASES of the HEART, LUNGS, 
STOMACH, LIVER, &c, OCCA- 
SIONED BY SPINAL IRRITA- 
TION: AND ON THE NERVOUS 
SYSTEM IN GENERAL, AS A 
SOURCE OF ORGANIC DISEASE. 
Illustrated by Cases. By John Marshall, 
M.D. 312 pages. 



and of Articles in the Eclectic Journal of Medicine. 



3 



6. A TREATISE ON INSANITY AND 
OTHER DISEASES AFFECTING 
THE MIND. By James Cowles Prich- 
ard, M.D. F.R.S. Corresponding Mem- 
ber of the Institute of France, &c. 340 
pages. 

" The author is entitled to great respec. for his 
opinions, not only because he is well known as 
a man of extensive erudition, but also on ac- 
count of his practical acquaintance with the 
subject on which he writes. The work, we may 
safely say, is the best, as well as the latest, on 
mental derangement, in the English language." 
— Medico- Chir. Rev. 

7. BOUILLAUD ON ACUTE ARTI- 
CULAR RHEUMATISM IN GEN- 
ERAL. Translated from the French, for 
this Library, by James Kitchen, M.D., 
Philada. 64 pages. 

8. A PRACTICAL TREATISE ON 
THE PRINCIPAL DISEASES OF 
THE LUNGS. Considered espe- 
cially IN relation to the particu- 
lar Tissues affected, illustrating 
the different kinds of cough. by 
G. Hume Weatheihead, M.D., Member 
of the Royal College of Physicians, 
Lecturer on the Principles and Practice 
of Medicine, and on Materia Medica 
and Therapeutics, &c. &c. 90 pages 

EPIDEMICS of the MIDDLE AGES. 
From the German of I. F. C. Hecker, 
M.D., &c. &c Translated by R. G. 
Babington, M.D. F.R.S. — 

9. No. I.— THE BLACK DEATH IN 
THE 14th CENTURY. 74 pages. 

" Hecker's account of the ' Black Death,' which 
ravaged so large a portion of the globe in the 
fourteenth century, may be mentioned as a work 
worthy of our notice, both as containing many 
interesting details of this tremendous pestilence, 
and as exhibiting a curious specimen of medical 
hypothesis." — Cyclopedia of Practical Medicine — 
History of Medicine by Dr. Bostock. 



10. No. II.— THE DANCING MANIA 

84 pages. 

<; Medical History has long been in need of the 
chapter which this book supplies ; and the defi- 
ciency could not have been remedied at a better 
season. On the whole, this volume ought to be 
popular; to the profession it must prove highly 
acceptable, as conveying so much information, 
touching an important subject which had almost 
been suffered to be buried in oblivion, and we 
think that to Dr. Babington especial thanks are 
due for having naturalised so interesting a pro- 
duction. The style of the translation, we may 
add, is free from foreign idioms : it reads like an 
English original." — Lond. Med. Qaz. 

11. LECTURES on Subjects connected 
with CLINICAL MEDICINE. By 
P. M. Latham, M.D. Fellow of the 
Royal College of Physicians, and Phy- 
sician to St. Bartholomew's Hospital. 
156 pages. 

" We strongly recommend them [Latham's . 
LecturesJ to our readers; particularly to pupils 
attending the practice of our hospitals." — Lond. 
Med. Gaz. 

12. ELEMENTS OF SURGERY, in 
Three Parts. By Robert Liston, Fel- 
low of the Royal College of Surgeons 
in London and Edinburgh, Surgeon to 
the Royal Infirmary, Senior Surgeon 
to the Royal Dispensatory for the City 
and County of Edinburgh, Professor of 
Surgery in the London University, &c. 
&c. 250 pages. 

" In the present work, an endeavour has been 
made, in the first place, to lay down, correctly 
and concisely, the general principles which ought 
to guide the Practitioner in the management of 
constitutional disturbance, however occasioned. 

" The observations introduced to illustrate the 
doctrines inculcated, are given as briefly as is 
consistent with an accurate detail of symptoms 
and results. The descriptions of particular dis- 
eases have been sketched and finished from na- 
ture; and, it is hoped, with such fidelity, that 
their resemblance will be readily recognized. 

" Such modes of operating are described, as 
have been repeatedly and successfully performed 
by the Author." 



JOURNAL DEPARTMENT. 

In the ECLECTIC JOURNAL OF MEDICINE, Vol. I., or First Year, 

HAVE BEEN PUBLISHED, 

Original Articles on Retrospection in Medicine, Clinical Medicine, Medical 
Education, Medical College of Philadelphia, Phrenology, &c. ; and Reviews on 
the following works: — Parish on Strangulated Hernia, Gerhard on the Diagnosis 
of Diseases of the Chest, Littell on Diseases of the Eye, Duparcque on Diseases 
of the Uterus, Hall on the Nervous System and its Diseases, Mackintosh's 
Practice of Physic, Armstrong's Lectures, Sewall on Phrenology, Hayward on 
Diseases of the Knee Joint, Alexander on the Capillary Blood- Vessels, &c, &c. 
Digests of Chomel on Typhoid Fever, Randolph's Experience in Lithotripsy, 
Osborne and Bright on Diseased Kidney and the Pathology and Treatment of 
Dropsy, Bouillaud on Diseases of the Heart, Lewins's Remarks on the Physi- 
ological and Therapeutic Effects of Colchicum, Knox on the Pulsations of the 
Heart, Observations and Experiments on Softening, Erosion, and Perforation of 
the Stomach, by Imlach, &c. Numerous articles on Physiology, Pathology, 
Therapeutics, Midwifery, Surgery, and Hygiene, embracing new views of dis- 
ease and modes of practice. 

O" The works enumerated above, with the Eclectic Journal, can be obtained, bound 
m 6 vols., for $13. 



4 Catalogue of Works published in the Select Medical Library, 



In the Library, Second Year, 

FROM NOVEMBER, 1837, TO OCTOBER, 1838, 

HAVE BEEN PUBLISHED, 



1. A PRACTICAL TREATISE ON 
DISEASES OF THE SKIN, ar- 
ranged with a view to their Constitu- 
tional Causes and Local Character, &c. 
By SAMUEL PLUM BE, lale Senior 
Surgeon to the Royal Metropolitan In- 
firmary for Children, &,c. Illustrated 
with Splendid Coloured Copperplate 
and Lithographic Engravings. 396 pp. 

• ' This work, which has long been a standard 
on Cutaneous Diseases, is, in this new edition, 
brought down by the Author to the present state 
of our knowledge ; a clear compendium is pre- 
sented of the recent discoveries of Chevallier, 
Breschet, and Vauzeme. The illustrations of 
cutaneous disease are happily exhibited, and are 
essential accompaniments. It is an able, in- 
structive, and elaborate production, and indis- 
pensable to the medical man." — Annals of Medi- 
cine, January, 1837. 

Plumbe on Diseases of the Skin.^" This excel- 
lent Treatise upon an order of diseases, the pa- 
thology of which is, in general, as obscure as the 
treatment is empirical, has just been republished 
in the Select Medical Library, edited by Dr. John 
Bell, of this city. We hail with pleasure the 
appearance of any new work calculated to elu- 
cidate the intricate and ill-understood subject of 
skin-diseases. The late Dr. Mackintosh, in his 
Practice of Physic, recommends it as the ' best 
pathological and practical treatise on this class 
of diseases, which is to be found in any lan- 
guage.' "—Phil. Med. Exam., Jan. 17, 1838. 

" This work is one of the most excellent on 
the Diseases of the Skin, in the English lan- 
guage." — West. Jour, of Med. and Phys. Sciences, 
Jan. 1838. 

2. THE MEDICAL PROPERTIES of 
the NATURAL ORDER RANUN- 
CULACE^E, &c. &c By A. Turn- 
bull, M.D. 72 pages. 

3. THE GUMS ; with late Discoveries on 
their Structure, Growth, Connections, 
Diseases, and Sympathies. By George 
VVaite, Member of the London Royal 
College of Physicians. 80 pages. 

4. A PRACTICAL TREATISE ON 
MIDWIFERY; Containing the Re- 
sults of Sixteen Thousand Six Hun- 
dred and Fifty-four Births, occurring in 
the Dublin Lying-in Hospital. By Ro- 
bert Collins, M.D., Late Master of 
the Institution. 264 pages. 

" Several reprints of great value have already 
appeared in the Library — among others, Prich- 
ard on Insanity, Curling on Tetanus, Latham's 
Clinical Lectures, &c. The Number for the pre- 
sent month commences Collins's Treatise on 
Midwifery, a work rich in statistical details." — 
Phil. Med. Exam., Jan. 17, 1838. 

" The seventeenth Number of Dr. Bell's Select 
Medical Library contains the conclusion of ' A 
Practical Treatise on Midwifery, by Robert Col- 
lins, M.D., Fhysician of the Dublin Lying-in 
Hospital.' — The| author of this work has em- 
ployed the numerical method of M. Louis ; and 



by accurate tables of classification, enables his 
readers to perceive, at a glance, the conse- 
quences of the diversified conditions, in which 
he saw his patients. Avast amount of informa- 
tion is thus obtained, which is invaluable to 
those who duly appreciate precision in the ex- 
amination of cases." — Bait. Chron. 

5. A PRACTICAL TREATISE ON 
THE MANAGEMENT AND DIS- 
EASES OF CHILDREN. By Rich- 
ard T. Evan son, M.D., Proiessor of 
Medicine, — and Henry Maonsell, 
M.D. Professor of Midwifery, — in the 
College of Surgeons in Ireland. 300 
pages. 

" The authors of the work before us, have had 
the advantage of investigating the subject of 
Infantile Diseases, conjointly in a public insti- 
tution — an advantage which no private medical 
man, however extensive his practice, could pro- 
bably have. The observations being made con- 
jointly too, offer a greater guarantee of correct- 
ness and authenticity, than if they emanated 
from a single source, however respectable. From 
their acquaintance, also, with foreign works, 
they have been able to bring up the Anatomy, 
Physiology, Pathology, and even Therapeutics, 
to a far higher level than is to be found in any 
previous work in the English language. 

" The second chapter embraces the Manage- 
ment and Physical Education of Children. This 
chapter ought to be printed in gold letters, and 
hung up in the nursery of every family. It 
would save many lives, and prevent much suf- 
fering." — Medico- Chirurg. Rev. 

" We know of no work to which, on the 
whole, so little can be objected in matter or 
manner. It is an elegant and practical com- 
pendium of Infantile Diseases; a safe guide in 
the Management of Children ; and completely 
fulfils the purposes proposed." — British Annals 
of Medicine, No. VIII. 

6. THE SURGEON'S PRACTICAL 
GUIDE IN DRESSING, and in the 
Methodic APPLICATION of BAND- 
AGES. Illustrated by one hundred 
engravings. By Thomas Cutler.M.D. 
late Staff Surgeon in the Belgian Army. 
92 pages. 

"Cutler on Bandages, with one hundred il- 
lustrative Engravings, will be invaluable to the 
great majority of the profession, throughout this 
country. But few have had the opportunity, 
which a large hospital only affords, of becoming 
acquainted with the best mode of applying ap- 
paratus, in cases of wounds, fractures, disloca- 
tions, &c. The plates and descriptions of this 
work, give this important information."— Bait. 
Chron. 

7. ON THE INFLUENCE OF PHY- 
SICAL AGENTS ON LIFE. By 
W. F. Edwards, M.D., F.R.S., etc. 
Translated from the French, by Drs. 
Hodgkin and Fisher. To which are 
added, some Observations on Electrici- 
ty, and Notes to the work. 228 pages. 

" This is a work of standard authority in 
Medicine ; and, in a physiological point of view , 



and of Articles in the Eclectic Journal of Medicine. 5 



is pre-eminently the most valuable publication 
of the present century ; the experimental inves- 
tigation instituted by the author, having done 
much towards solving many problems hitherto 
but partially understood. The work was origi- 
nally presented in parts to the Royal Academy 
of Science of Paris, and so highly aid they esti- 
mate the labours of the author, and so fully ap- 
preciate the services by him thus rendered to 
science and to humanity, that they awarded 
him, though a foreigner, the prize founded for 
the promotion of experimental physiology. 

"His researches relate to what are denomi- 
nated the Physical Agents, viz: Temperature, 
as modified in degree and duration; Electricity; 
Air, as regards quantity, motion or rest, density 
or rarity ; Water, as a liquid and in a state of 
vapour; and Light; and his object is to show 
the effects produced on the human system by 
these agents which surround and are incessantly 
exercising an influence upon us. 

" It is hardly necessary for us to say, that the 
design has been executed in a masterly man 
ner, and that the profession is under deep obliga- 
tions to Dr. Edwards, for so satisfactorily per- 
forming his task, and furnishing it with such a 
body of facts, and such a vast number of experi 
ments, in illustration and confirmation of his 
views." — Prov. Jour. 

8. Prof. HORNER'S NECROLO- 
GICAL NOTICE OF DR. P. S. 
PHYSICK; Delivered before the 
American Philos. Society, May 4, 
1838. 32 pages. ■ 

9. ESSAYS ON PHYSIOLOGY 
AND HYGIENE ; 250 pp., viz : 

I. REID'S EXPERIMENTAL IN- 
VESTIGATION into the FUNC- 
TIONS of the EIGHTH PAIR 
OF NERVES. 

II. EHRENBERG'S MICROSCO- 
PICAL OBSERVATIONS on the 
BRAIN AND NERVES (with 

NUMEROUS ENGRAVINGS). 

III. ON THE COMBINATION OF 
MOTOR and SENSITIVE NER- 
VOUS ACTIVITY; by Professor 
Stromeyer, Hanover. 

IV. VEGETABLE PHYSIOLOGY. 

V. EXPERIMENTS ON THE 



BRAIN, SPINAL MARROW, 
and NERVES. By Prof. Mayer, 
of Bonn (with woodcuts). 

VI. PUBLIC HYGIENE. 

VII. PROGRESS of the ANATO- 
MY and PHYSIOLOGY of the 
NERVOUS SYSTEM, during 
1836, By Professor Muller. 

VIII. VITAL STATISTICS. 

10. CURIOSITIES OF MEDICAL 
EXPERIENCE. By J. G. Mil- 
lingen, Surgeon to the Forces, 
Member of the Medical Society of 
the Ancient Faculty of Paris, etc., 
etc. 372 pages. 

" Curiosities of Medical Experience. By J. G. 
Millingen, Surgeon to the Forces, etc. The 
Author or Compiler derived the idea which 
prompted him to write this work from D'Israeli's 
'Curiosities of Literature;' and, in our view, 
he has made a book equally curious in its way 
with that one. The heads of his chapters are 
numerous and varied; and all his subjects are 
treated in an agreeable and comprehensible 
style to the general reader. The drift of the 
Author, too, is decidedly useful. We shall en- 
deavour to give some extracts from this work." 
—Nat. Gaz. 

11. MEDICAL CLINIC; or, Re- 
ports of Medical, Cases: By G. 
Andral, Professor of the Faculty 
of Medicine of Paris, etc. Con- 
densed and Translated, with Obser- 
vations extracted from the Writings 
of the most distinguished Medical 
Authors : By D. Spillan, M.D., 
etc., etc. ; containing Diseases of the 
Encephalon, &c, with Extracts from 
Ollivier's Work on Diseases of the 
Spinal Cord and its Membranes. 
300 pages. 

12. AN ESSAY ON DEW, and several 
Appearances connected with it; by 
William Charles Wells, M.D. 
F.R.S., etc. 72 pages. 



JOURNAL DEPARTMENT. 

In the ECLECTIC JOURNAL OF MEDICINE, Vol. II., or Second Year, 
have been published, 

Original Articles on Animal Magnetism, Laryngeal Phthisis, Elepbantiasis, 
trie Use and Abuse of the Pessary, Dislocation of the Elbow Joint, Lithotripsy, 
Pneumonia Typhoides, Excision of the Neck of the Uterus, the Plague of 
Athens, translated from the Greek of Thucydides; the Application of Turpen- 
tine in Tetanus, Medical Schools and Professorships, the Use of the Balsam of 
Copaiba in Diseases of the Mucous Membrane of the Intestinal Canal, on an 
Improved Auriscope — with engraving; the Solar Speculum — with engraving, 
&c. ; and Reviews on the following Works : Meigs's Philadelphia Practice of 



6 Catalogue of Works published in the Select Medical Library, 



Midwifery; the Medical Examiner, and other Journals; the Boylston Prize 
Dissertations for 1836-7 ; Millingen's Curiosities of Medical Experience ; Popu- 
lar Medicine, or Family Adviser, by Reynell Coates ; Caldwell's Vindication of 
Phrenology; Velpeau's Anatomy of Regions ; Mutter's Cases of Autoplastic; 
Graham on Epidemic Diseases; Smiles on the Physical Education of Children ; 
Jeanes's Homoeopathic Practice of Medicine; Ryan's Philosophy of Marriage, 
&c. ; Hooker's Essay on the Relation between the Respiratory and Circulating 
Functions; &c, &'c. Digests of Brigham's Mental Culture on Health; the 
Medical Section of the British Association for the Advancement of Science ; 
Qnetelet on Man, and the Development of his Faculties ; Oppenheim on the 
State of Medicine in Turkey; Memoirs of the Royal Academy of Medicine; 
Colles, Hunter, and Devergie, on the Treatment of Venereal Diseases by Mer- 
cury ; Combe's Remarks on Tiedemann's Comparison of the Negro Brain and 
Intellect with those of the European: Mitcherlich on Diuretic Medicines; 
Helm on Puerperal Diseases ; Scudamore on Heat, &c, &c. Numerous Arti- 
cles on Physiology, Chemistry, Pathology, Therapeutics, Midwifery, Surgery, 
and Hygiene, embracing new views of diseases and modes of practice; with an 
Index and Title-pao-e, — forming a handsome volume of near five hundred closely 
printed pages; which, with the LIBRARY, amounts to near THREE 
THOUSAND pages for TEN DOLLARS; containing as much matter, (and 
that selected from the best authors,) as in ordinary medical works would occupy 
five thousand pages, or twelve volumes. 

D3 3 The Works published in the Second year, as enumerated above, with the Eclectic 
Journal, can be obtained bound in 6 vols, "for $13. — Or the first and second years to* 
gether, uniform, 12 vols, for $26. 



In the I* library, Third Year, 

COMMENCING NOVEMBER, 1838, AND ENDING OCTOBER, 1839, 

HAVE BEEN PUBLISHED, 



1. LECTURES ON THE PHYSIO- 
LOGY AND DISEASES OF THE 
CHEST; including the Principles of 
Physical and General Diagnosis. De- 
livered during the Spring Sessions of 
1836 and 1837, at the Anatomical 
School, Kinnerton Street, near St. 
George's Hospital. By Charles J. B 
Williams, M.D., F.R.S. Professor of 
the Principles and Practice of Medicine 
in University College, London. With 
Engravings. 

2. ESSAY UPON THE QUESTION, 
IS MEDICAL SCIENCE FAVOR- 
ABLE TO SCEPTICISM ? By 
James W. Dale, M.D., of Newcastle, 
Delaware 

3. LECTURES ON THE PRINCI- 
PLES OF SURGERY. By John 
Hunter, F.R.S. With Notes by 
James F. Palmer, Senior Surgton to 
the St. George's and St. James'sJDispeii- 
saries, &c. &c. With Plates. 

"We have perused these lectures with no or- 
dinary feelings of satisfaction. They embody an 
immense amount of important facts, directed 



with no common skill to the illustration and 
improvement of medical science generally, and 
of the surgical department in particular. Indeed 
we have no hesitation in saying, that, whatever 
be the position of the reader in the profession, he 
will not relinquish the perusal of these lectures 
without the consciousness of having usefully 
employed the time which he may have bestowed 
upon them. For they constitute, in the fullest 
sense of the term, a philosophical disquisition on 
the science of Surgery ; and hence, embracing 
the great principles on which the whole art of 
healing rests, their interest will be felt by all 
who regard Medicine asa true branch of science, 
and who delight to witness the gradual develop- 
ment of prineiples in the right interpretation of 
the phenomena of nature." 

" We cannot bring our notice of the present 
volume to a close without offering our testimony 
to the admirable manner in which the editor and 
annotator has fulfilled his part of the underta- 
king. The advancements and improvements 
that have been effected, up to our own day, not 
only in practical surgery, but in all the collate- 
ral departments, are constantly brought before 
the reader's attention in clear and concise 
terms." — Brit. For. Med. Rev. 

" The surgical lectures alone were sufficient 
to fix us long in our chair, and our pains were 
amply compensated by the perusal of the very 
words in which Hunter had instructed his class." 

" The rescuing of these lectures from that ob- 
livion which they must needs have fallen into in 
private hands, alone constitutes the editor of 



and of Articles in the Eclectic Journal of Medicine. 



Hunter's works a benefactor to the student and 
the scholar."— Medical Gazette. 

4. ON DENGUE; ITS HISTORY, PA- 
THOLOGY, AND TREATMENT. 
By S. Hknry Dickson, M.D., Pro- 
fessor of the Institutes and Practice of 
Medicine in the Medical College of S.C. 

5. OUTLINES OF GENERAL PA- 
THOLOGY. By George Freckle- 
ton, M.D., Fellow of the Royal College 
of Physicians. 

6. URINARY DISEASES and their 
TREATMENT. By Robert Wil- 
lis, M.D., Physician to the Royal In- 
firmary for Children, &c. &c. 

"We do not know that a more competent au- 
thor than Dr. Willis could have been found to 
undertake the task ; possessing, as it is evident 
from his work that he does possess, an accurate 
acquaintance with the subject in all its details, 
considerable personal experience in the diseases 
of which he treats, capacity for lucid arrange- 
ment, and a style of communication commenda- 
ble in every respect." 

" Our notice of Dr. Willis's work most here 
terminate. It is one which we have read and 
trust again to read with profit. The history of 
discovery is successfully given; cases curious and 
important; illustrative of the various subjects 
have been selected from many new sources, as 
well as detailed from the author's own experi- 
ence, chemical analyses, not too elaborate, have 
been afforded, which will be most convenient to 
those who wish to investigate the qualities of 
the urine in disease; the importance of attend- 
ing to this secretion in order to a proper under- 
standing ot disease is strongly insisted upon ; in 
short, a book has been composed, which was 
much required, and which we can conscientious. 
]y and confidently recommend as likely to be 
useful to all classes of practitioners.— Brit, 
For. Med. Rev. 

7. LECTURES on BLOOD-LETTING. 
By Henry Clutterbuck, M.D. 

8. THE LIFE OF JOHN HUNTER, 
F.R.S. By Drewry Ottley. 

"In the summing up of Mr. Hunter's character, 
Mr. Ottley exhibits equal judgment and can- 
dour."— Brit. Sf For. Med. Rev. 

9. HUNTER'S TREATISE ON THE 



VENEREAL DISEASE. With Notes 
by Dr. Babington. With Plates. 

"Under the hands of Mr Babington, who has 
performed his task as editor in a very exempla- 
ry manner, the work has assumed quite a new 
value, and may now be as advantageously 
placed in the library of the student as in that of 
the experienced surgeon.— Brit. # For. Med. Rev. 

" The notes, in illustration of the text, con- 
tain a summary of our present knowledge on 
the subject, the manner in which these notes 
areconstructed is at once clever and perspicuous; 
arid the modes of treatment prescribed, spring 
from a right apprehension of the disease. We 
would recommend to the reader the note on the 
primary venereal sore ; the note itself is an es- 
say in every word of which we fully concur." — 
Med. Gazette. 

10. A TREATISE ON THE TEETH. 
By John Hunter. With Notes by 
Thomas Bell, F.R.S. With Plates. 

" The treatise on the teeth is edited by Mr, 
Bell, a gentleman accomplished in his art. Mr. 
Bell has studied his subject with the greatest mi- 
nuteness and care; and in appropriate notes at 
the first of the page corrects the author with 
the air of a gentleman, and the accuracy of a 
man of science. The matter contained in these 
short notes forms an ample schoJum to the text; 
and without aiming at the slightest display of 
learning, they at the same time exhibit a ready 
knowledge on every point, and an extensive in- 
formation both of comparative anatomy and 
pathology. — Med. Gazette. 

It. MEDICAL AND TOPOGRAPHI- 
CAL OBSERVATIONS upon the 
MEDITERRANEAN and upon POR- 
TUGAL, SPAIN, AND OTHER 
COUNTRIES. By G. R. B. Hor- 
ner, M.D., Surgeon U. S. Navy, and 
Honorary Member of the Philadelphia 
Medical Society. With Engravings. 
" An uncommonly interesting book is present- 
ed to those who have any disposition to know 
the things medical in Portugal, Spain, and 
other countries," and ' will doubtless be read, 
also, with marked satisfaction by all who have 
a taste for travels." — Bost. Med. and Surg. Jour. 

12. LECTURES ON THE BLOOD, 

AND ON THE CHANGES WHICH IT 
UNDERGOES DURING DISEASE. By 
F. Magendie, M.D. 



JOURNAL DEPARTMENT. 

In the ECLECTIC JOURNAL OF MEDICINE, Vol, III, or that for 
the Third Year, 1838-9, have been published, 
Original Reviews and Bibliographical Notices, viz., of Hosack's Lectures 
on the Theory and Practice of Physic, Walker on Intermarriage, the Works of John 
Hunter, Introductory Lectures, Deslandes on diseases produced hy Onanism, Gran- 
ville on Counter-Irritation, Gallop's Outlines of the Institutes of Medicine, Bouvier 
on Club Foot, Harris's Dental Surgery, Vimont on Human and Comparative Physi- 
ology, New York Journal of Medicine and Surgery, Madam Boivin's Art of Mid- 
wifery, &c, &c: also, Selected Reviews of Lonsdale and Burke on Fractures, 
Foissac on the Influence of Climate, Lecanu and Denis on the Chemistry of the 
Blood, Gondret &c. on Counter-Irritation, &c, &c: Proceedings of the Medical 
Section of the British Association, Papers on Club Fool, Yellow Fever, Pathology 
of the Ovaria, Extirpation of the Parotid Gland, Endermic Medicine, Simple 
Ulceration of the Stomach, Artificial Digestion, Diseases of the Kidneys, Diseases 
of she Spine, Irritable Bladder, Fibres of the Spinal Marrow, Experiments on the 
Blood, Galvanic Experiments on a Dead Body, &c, &c., and numerous other 
articles on Therapeutics, Pathology, Surgery, and Midwifery. 



8 



Catalogue of Books, etc. 



In the Library, Fourth Year, 

COMMENCING NOVEMBER 1839, AND ENDING OCTOBER 1840, 



HAVE BEEN PUBLISHED, 



2, 



MEDICAL NOTES AND REFLEC- 
TIONS. By Henry Holland, M.D., 
F.R.S., Fellow of the Royal College of 
Physicians, and Physician Extraordi- 
nary to the Queen. 

CLINICAL REMARKS ON SOME 
CASES OF LIVER ABSCESS PRE- 
SENTING EXTERNALLY. By 
John G. Malcolmson, M.D. Surgeon 
Hon. E. I. C. Service, Fellow of the 
Royal Asiatic Society, and the Geolo- 
gical Society, London. 

3. HISTORICAL NOTICES ON THE 
OCCURRENCE OF INFLAMMA- 
TORY AFFECTIONS OF THE IN- 
TERNAL ORGANS AFTER EX- 
TERNAL INJURIES AND SUR- 
GICAL OPERATIONS. By Wil- 
liam Thompson, M.D., &c. &c. 

4. AN EXPERIMENTAL INVESTI- 
GATION INTO THE FUNCTIONS 
OF THE EIGHTH PAIR OF 
NERVES- By John Reid, M.D., &c. 

5. TREATISE ON THE BLOOD, IN- 
FLAMMATION, AND GUN-SHOT 
WOUNDS. By John Hunter, F.R.S. 
With Notes, by James F. Palmer, 
Senior Surgeon to the St. George's 
and St. James's Dispensary, &c, &c. 
A PRACTICAL TREATISE ON 
VENEREAL DISORDERS, AND 
MORE ESPECIALLY ON THE 
HISTORY AND TREATMENT OF 
CHANCRE. By Philippe Ricord, 
M.D., Surgeon to the Venereal Hos- 
pital at Paris. 

A TREATISE ON INFLAMMA- 
TION. By James Macartney, F.R.S. , 
F.L.S., &c, &c. Member of the Royal 
College, of Surgeons, London, &c, &c. 



6. 



7, 



8. AMUSSAT'S LECTURES ON 
THE RETENTION OF URINE, 
CAUSED BY STRICTURES OF 
THE URETHRA, and on the Diseases 
of the Prostrate, translated from the 
French by James P. Jervey, M.D, 

9. OBSERVATIONS ON CERTAIN 
PARTS OF THE ANIMAL CECON- 
OMY, Inclusive of several papers from 
the Philosophical Transactions, &c. By 
John Hunter, F.R.S., &c, &c. With 
Notes by Richard Owen, F.R.S. 

" One distinctive feature of the present edition 
of Hunter's works has been already mentioned, 
viz: in the addition of illustrative notes, which 
are not thrown in at hazard, but are written by 
men who are already eminent for their skill and 
attainments on the particular subjects which 
they have thus illustrated. By this means, whilst 
we have the views entire ol John Hunter in the 
text, we are enabled by reference to the accom 
panying notes, to see wherein the author is borne 
out. by the positive knowledge of the present, day, 
or to what extent his views require modification 
and correction. The names of the gentlemen 
who have in this manner assisted Mr. Palmer, 
are guarantees of the successful performance of 
their t ask. 

10. HINTS ON THE MEDICAL EX- 
AMINATION OF RECRUITS FOR 
THE ARMY; and on the Discharge 
of Soldiers from the Service on Sur- / 
geon's Certificate : Adopted to the Ser- 
vice of the United States. By Thomas 
Henderson, M. D., Assistant Surgeon 
U. S. Army, &c, &c. 

11. AN ESSAY ON HYSTERIA; being 
an analysis of its irregular and aggravated 
forms; including Hysterical Hemorrhage 
and Hysterical Ischuria. With numer- 
ous Illustrations and Curious Cases. 
By Thomas Laycock, House Surgeon 
to the York County Hospital. 



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ment, Nov. 1, 1836; from No. XIII, Nov. 1, 1837; from No. 
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prices. 



LECTURES 



ON THE 

THEORY AND PRACTICE 

OP 

PHYSIC. 



BY WILLIAM STOKES, M.D., 

LECTURER AT THE MEDICAL SCHOOL, PAKK STKEET, DUBLIN; PHYSICIAN TO THE 
HEATH HOSPITAL, ETC., ETC. 



SECOND AMERICAN EDITION. 



WITH 

NUMEROUS NOTES, AND TWELVE ADDITIONAL LECTURES, 



JOHN BELL, M.D., 



LECTURER ON THE INSTITUTES OF MEDICINE AND MEDICAL JURISPRUDENCE ; 
FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; 
CORRESPONDING SECRETARY OF THE PHILADELPHIA MEDICAL COLLEGE; 
MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, AND OF THE GEORGOFILI 
SOCIETY OF FLORENCE, ETC., ETC. 



HASWELL, BARRING TON, AND HASWELL. 
NEW ORLEANS: JOHN J. HASWELL & CO. 
NEW YORK: J. & H. G. LANGLEY.- CHARLESTON: W. H. BERRETT. 
RICHMOND: SMITH & PALMER. 

1840. 



Entered according to act of Congress, in the year 1840, by Haswell, Bar- 
rington, & Haswell, in the clerk's office of the district court for the eastern 
district of Pennsylvania. 



2. 




EDITOR'S PREFACE. 



In yielding to the wish of the publishers that he would become 
annotator to the " Lectures" of Doctor Stokes, and make additions on 
subjects not included in the course of the distinguished lecturer in 
the Park Street Medical School, the editor was not unmindful of 
the responsibility of his task, nor of the comparisons to which his 
labours would be subjected by critical readers. Mere self-regard 
would have made him prefer to be the author of a separate work 
on the Practice of Medicine ; in which scope would have been 
allowed him for various topics necessarily omitted on the present 
occasion. But he was consoled by the reflexion, that, next to the 
pleasure of original promulgation of sound precepts of doctrine and 
practice by oneself, is that of bearing corroborative testimony to 
emanations of this nature from another person. 
. The edi-tor has not found it necessary, in the discharge of his 
functions, to deviate from the course of enlightened eclecticism pur- 
sued by Dr. Stokes. Diagnosis, a too much neglected part of 
American medicine, is opened out by this gentleman with a fulness 
and accuracy of specification, which the guidance of patholo- 
gical anatomy alone could give: and attention, by this means, being 
directed to the suffering organ, the therapeutical indications, though 
not necessarily inferred, are placed in more obvious relief than they 
could possibly be, if we were left to peer through the mist of con- 
jectural symptomatology. The primary condition for solving suc- 
cessfully the problem of disease by its cure, is, of necessity, a clear 
perception of its material seat ; the whereabouts and the what, 
identification and detection, must ever precede removal. One, and 
not the least of the merits o fthe Dublin school of medicine, so ably 
represented on this occasion by Dr. Stokes, is in its large and 
judicious borrowing from the French discoveries in morbid anatomy, 
and in combining the deductions which they supply with Hippocratic 
observation of symptoms and the externals of disease, so as to form 
a harmonious body of doctrine of general pathology and diagnosis. 
It is not, however, pretended that the therapeutical treatment will 
follow as an obvious deduction from these pathological premises; but 
very surely will pathology serve to teach a wise caution in the selection 
of remedies, a proper appreciation of their real effects on the tissues 
and organs of the body, and a prudent forbearance from their em- 
ploymentwhen the diseased organ canneither be reached, noritsmor- 
bid alterations corrected by any of the aids of art. In the manner of 
treating certain organic affections of, severally, the brain, lungs and 
heart, wesee cogent examples of the advantages which a correct diag- 
nosis gives to the instructed physician over the superficial symptoma- 
tologist. But it is not necessary to dilate hypothetically on themes 
which are so ably discussed and practically illustrated by Dr. Stokes 



8 



PREFACE. 



in the present volume. Of the success with which he has performed 
his task,Dr. Dunglison, who has the merit of being the first to collect the 
"Lectures," from the different numbers of a London Medical Journal 
through which they were dispersed, for publication in his American 
Medical Library, very appropriately remarks : — " He is not aware 
of any work in which the topics treated of are displayed in a more 
attractive, and at the same time a more instructive, manner." 

The notes of the editor interspersed through the first and chief 
portion of the present volume, and designated by his initials, and his 
subsequent more formal additions, have been written in the same 
spirit with that of the original lectures ; viz., an avoidance of specu- 
lative setiology, emphasis on diagnosis deduced from morbid ana- 
tomy, and a recommendation of therapeutics, simple yet energetic, 
so far as they are indicated by the phenomena of the disease, and 
the repeated enforcements of experience. The chief subjects of the 
notes are Ileitis in connection with Typhoid fever, Sporadic Dys- 
entery, Bilious Colic, Inflammation of the Ccecum — the two last not* 
described by Dr. Stokes; Hepatic Abscess; Encephalitis illustrating 
phrenology ; Softening of the Brain ; Apoplexy as dependent on hyper- 
trophy of the heart ; Paraplegia ; Neuralgia ; Scrofula, and In- 
termittent Fever. The additional lectures, twelve in number, by 
the editor, are on Typhous, Congestive, and the Eruptive Fevers; 
Rheumatism, acute and chronic, and Chronic Laryngitis. His in- 
tention originally was to embody all his additions in the form of 
lectures, to come after those of Dr. Stokes, on diseases not treated of 
by this gentleman ; and, accordingly, he had made considerable 
progress in a carefully prepared digest of the pathology and treat- 
ment of the diseases of the Respiratory System, beginning with 
simple erythematic laryngitis, and ending with tubercular phthisis 
pulmonalis. Of all the matter originally written for this purpose, 
the change in his arrangements has allowed him to bring out at 
this time only his lectures on Rheumatism and Chronic Laryngitis. 

The substitution of his lectures on Congestive Fever for those on 
other diseases written by the editor, will, it is believed, be acceptable 
to his younger professional brethren, particularly to those residing 
in the Southern and Western sections of the Union. Even the ful- 
ness of description and occasional iteration of important points in 
pathology and therapeutics, as well as the remarkson collateral topics, 
especially the spurious hepatic pathology and the mercurial practice, 
will, he hopes, find favour in consideration of their aim and tendency, 
although they may not have been discussed with entire success. It will 
not be thought presumptuous in him to have endeavoured to open 
the whole field of observation and inquiry on congestive fever, to 
correct serious misapprehensions of its character, and to prepare a 
way for its better treatment, by dwelling on once familiar but, of late, 
forgotten truths. 

In conclusion, he believes that the present work, which is not 
offered as a substitute fitted to supplant them in public estimation, 
will be received as a positively valuable addition to existing medi- 
cal summaries and Systems of Practice. 



CONTENTS 



TO STOKES'S LECTURES. 



LECTURE I. 

General Observations ...... page 17 

LECTURE II. 

General remarks on local diseases — Fixed rules for the guidance of students — Great 
importance of diagnosis — Existence of pure fever rare — Doctrine of the Humoralist 
and of the Brownists — Pathology of the digestive system ... 29 

LECTURE III. 

Pathology and treatment of diseases of the digestive system — Different forms of gastri- 
tis — Pathology of this disease imperfectly understood by the ancients — Gastritis and- 
enteritis not always found in connection — Phenomena characterizing acute gastritis 
— Symptoms and sympathetic relations — Diagnosis — Gastritis simulating other dis- 
eases ......... 39 

LECTURE IV. 

Gastritis — No one symptom decidedly indicative of the particular condition of any 
organ — Sympathetic irritation liable to terminate in organic disease — Sympathetic 
relations as connected with the viscera of the thorax — Treatment of simple acute 
gastritis — Antiphlogistic remedies — Purgative medicines injurious — Enemas and 
injections — Use of ice beneficial — Effervescing medicine hurtful . 49 

LECTURE V. 

Pathology and treatment of gastritis — Application of blisters — Emetics can be seldom 
used in acute gastritis — Hsematemesis and delirium tremens complicated with gas- 
tritis — Treatment of these affections — Dyspepsia, or chronic gastritis — Hypochon- 
driasis — Termination of chronic gastritis ..... 57 

LECTURE VI. 

Treatment of chronic gastritis — Frequent excitement of the vascular system necessary 
to the performance of the functions of the stomach — Local bleeding — Regimen — 
Counter-irritation over the stomach — Treatment of Broussais — Use of vegetable 
tonics — Oxide of bismuth — Acetate of morphia ... 66 

LECTURE VII. 

Friction with croton oil — Attention to diet during convalescence — Organic disease of 
the stomach — Principles of treatment — Diet and attention to the bowels — Duodenitis 
— Inflammation of the jejunum — Ileitis, complication and nature of — Dothinenteri- 
tis — Ulceration of the mucous membrane — Symptoms and diagnosis of ileitis 74 

LECTURE VIII. 

Diseases of the small intestines — Symptoms of ileitis — Occurrence of diarrhoea with 
fever symptomatic of this form of inflammation — Frequency and symptoms of the 
disease in children — Tabes mesenterica, treatment of . , 83 

LECTURE IX. 

Treatment of ileitis — Advantage of leeching — Stimuli sometimes beneficial — Infantile 
remittent fever — Inflammation of the mucous membrane — Enteritis, with diarrhoea — 
Effects of opium in inflammation of serous and mucous membranes — Pathology and 
treatment of diarrhoea and dysentery — Perforation of the intestine — Diseases of the 
large intestine . . . . . . . . 91 

LECTURE X. 

Diseases of the large intestines — Treatment of diarrhoea— A pyrexial period of diarrhoea 
— Danger in suddenly arresting the discharge — Purging in phthisis — Dysentery — 
Epidemic dysentery ....... 103 

2* 



10 



CONTENTS. 



LECTURE XL 

Sporadic dysentery — Nature of this disease — Treatment ; mercurial, stimulating, anti- 
phlogistic — Recommendation of Dr. Elliotson— Success of Dr. O'Beirne in the use of 
tobacco injections — [Salivation not a necessary measure of the therapeutic effects of 
mercury in dysentery — Calomel in full doses early in the disease — Opiates when 
required — The form of disease requiring tonics — Gastric complications — Ipecacuanha 
in large doses without vomiting — Opium advised by some in large doses from the 
beginning — Rectal dysentery — Its treatment] — Tympanites, or meteorism — Windy 
colic, remedies for the cure of — [Notes on flatulent colic, bilious colic, inflammation 
of the csecum and tuphlo-enteritis] . . . . . 112 

LECTURE XII. 

Pathology of jaundice — Its co-existence with a flow of bile — Case of aneurism of the 
hepatic artery — The disease, independent of mechanical construction — Colouring of 
the various parts — Effects on the milk, and humours of the eye — Jaundice with pre- 
servation of health — Icterus infantum . . . . . 140 

LECTURE XIII. 

Jaundice from gastro-duodenitis — Researches of Broussais and Marsh on — Jaundice 
without hepatic inflammation — Nervous symptoms — Treatment — Yellow fever — its 
occurrence in this country — Predominance of gastric irritation in warm climates — 
Typhus icterodes — Jaundice from biliary calculi — Different situations in which 
biliary calculi may be found ...... 148 

LECTURE XIV. 

Diagnosis of jaundice from biliary calculi — Proof of the passage of the calculus — Indi- 
cations of treatment — Rupture of the gall-bladder after the use of emetics — Spasmo- 
dic jaundice — Treatment of spasmodic jaundice — Discharges of fatty matter — Re- 
searches of Drs. Bright and Elliotson — Connection with malignant disease examined 
— Source of fatty matter . . . . . . 158 

LECTURE XV. 

Acute and chronic hepatitis — Pathological differences — Effect of climate — General and 
local symptoms — Character of fever — Pain of shoulder — Use of pleximeter — Com- 
plication with jaundice — Resolution — Abscess — Various openings of the latter — 
Cicatrisation . ... . . . . . 166 

LECTURE XVI. 

Diagnosis of the rupture of hepatic abscess — Pulmonary openings — Case of double 
opening — Puncture of the gall-bladder — Gangrene of the liver — Its connection with 
hepatic apoplexy — Diagnosis of distended gall-bladder — Its causes — Inflammation of 
the parietes over the liver — Sympathy of the integuments . . 175 

LECTURE XVII. 

Aneurism of the hepatic artery — Distension of the liver with bile — Treatment of he- 
patitis — Employment of mercury — Symptoms of suppuration — Dr. Graves's operation 
for giving exit to matter in hepatic abscess — Rupture into the peritoneum — Uhronic 
hepatitis — Complication with disease of the heart — Embryonary state of the liver 1 84 

LECTURE XVIII. 

Treatment of chronic hepatitis — Neuralgia of the liver succeeding hepatitis — Connec- 
tion of hepatic with gastro-intestinal disease — Modes of transmission of disease from 
the mucous surface of the liver — Phlebitis of the vena porta — Obstruction of this 
vein — Case of pulmonary, hepatic, and intestinal fistulas — Hepatic neuralgia 194 

LECTURE XIX. 

Gastritis, with delirium tremens — Varieties of intestinal worms — Organization and 
origin of — Occurrence in the foetuses of various animals — Formation — Pathology of 
— Perforation of the intestines by — Worms in tumours and abscesses . 205 

LECTURE XX. 

Symptoms of intestinal worms — Sympathetic irritations — Affections of the nervous 
and respiratory systems — Various diseases mistaken for worms — Exciting causes of 
worms — Farinaceous and milk diet — Verminous fever — Treatment of worms — Speci- 
fic and mechanical purgatives ; calomel, turpentine, &c, &c. — Remedies for each 
species of worms — Preventive measures . . . . . 214 



CONTENTS. 



11 



LECTURE XXI. 

Painters' colic— Effect of metallic poisons on the nervous system— Symptoms of 
painters' colic — Pathology of neuroses — Action of lead on the syst m — Abdominal 
and cerebral symptoms — Species of painters' colic — Dr. Thomson's researches on 
lead — Effects of in animals — Effects of on the generative system . 223 

LECTURE XXII. 

Pathology of painters' colic — Researches on the state of the nervous and digestive 
systems — Treatment — Use of narcotics, purgatives, tobacco, &c, &c. — Treatment 
of paralysis from lead — Efficacy of strychnine and brucine — Colic from copper 
— Poisonous effects of mercury — Remarkable case — Affection of the respiratory 
muscles . . . . . . . . 232 

LECTURE XXIII. 

Diseases of the nervous system — Pathology of, unknown — Molecular change in the 
nervous centres — Difficulties of distinguishing arachnitis from encephalitis — Gene- 
ral and partial cerebritis — Symptomatology of — Diagnosis of — Preservation of intel- 
lect in — Production of general symptoms by local lesion. . . 241 

LECTURE XXIV. 

Encephalitis, diagnosis of — Preservation of function with organic disease — Vicarious 
actions of parts— Importance of pathology to phrenology — Use of pathology to phre- 
nologists — Arachnitis at the base of the brain — Symptoms of — Influence of age over 
the intellectual faculties — Opinions of Bouillaud, Serres, and Foville — Influence of 
the optic thalami and corpus striatum on the motions of the extremities — Diagnosis 
of disease of the cerebellum — Connection with the generative system — Remarkable 
cases of — [Discussions in the French Academy on] ... 25 

LECTURE XXV. 

Symptoms of encephalitis — Conclusions as to contraction and paralysis — Remarkable 
cases of encephalitis — Abscesses in the brain — Sympathetic affections — Enteritis 
simulating cerebritis — Prognosis in cerebritis — Remote neuralgia a symptom 267 

LECTURE XXVI. 

Encephalitis — Treatment of in the adult — Importance of energetic means — Dangerous 
effects of opening the temporal artery or jugular vein — Copious blood-letting from 
the arm — Difficulty of producing syncope — Employment of cold — Good effects from 
purgatives — Encephalitis caused by piles — Treatment — Beneficial effects of blisters 
— Mercury — Dangerous effects of emetics — Dessault's treatment — Use of opium — - 
Violent counter-irritation of coma — Application of boiling water — Treatment of par- 
tial encephalitis — [Softening of the Brain] .... 276 

LECTURE XXVII. 

Analysis of symptoms of cerebritis — Inconstancy of pain — Arachnitis, pain of — Inter- 
mittent pain — Headache — Phenomena of the eye — State of the pupils — Various 
affections of the functions of vision — Researches of Parent and Martinet — Relief by 
convulsions — Brain considered as a secreting organ — Dangerous effects of opium; 
delirium — Phenomena of organic life — Vomiting in hydrocephalus — Sympathies of 
the digestive and respiratory systems — Treatment of hydrocephalus — Of internal 
remedies — Cancrum oris, treatment of ..... 288 

LECTURE XXVIII. 

Apoplexy — Cerebritis and meningitis — Definition of apoplexy — Simple or nervous 
apoplexy without disorganization — Complicated with other diseases — Congestive or 
serous apoplexy — Dr. Abercrombie's opinions — Apoplexy with extravasation — Sites 
of extravasation — Absorption of clot — Apoplexy in children . . 301 

LECTURE XXIX. 

Apoplectic effusions — Curative process adopted by nature — Periods of life most subject 
to apoplexy — Connection of temperaments [and sex] with disposition to apoplexy — 
Researches of Rochoux — Principles of diagnosis — Varieties of apoplexy — Connec- 
tion of symptoms with pathological appearances — Rostan's division of — Different 
symptoms of — Double effusions — Rupture into ventricles — Hemiplegia — Value of the 
suddenness of paralysis as a diagnostic examined — Symptoms of apoplectic effu- 
sions ......... 310 



12 



CONTENTS. 



LECTURE XXX. 

Apoplexy from ramollissement (softening) of the brain— Supervention of apoplexy on 
encephalitis— Inflammation round the clot—Variety of paralysis consequent on 
apoplexy — Paralysis croissee — Different forms of paralysis — Origin — Phenomena of 
face and tongue — Paralysis of the tongue— Treatment of apoplexy — Blood-letting 
—Purgatives — Lotions, beneficial effects of — Emetics, dangerous effects of — Use of 
revulsives and stimulants — Treatment of paralysis — Efficacy of strychnine — Its 
modus operandi — Brucine, its proposed employment . . • 318 

LECTURE XXXI. 

Local treatment of paralysis — Flesh-brush, shower-bath, &c. — Application of moxa — 
Cases in which it is useful — Professor M'Namara's plan — Acupuncture with galva- 
nism — Electro-puncturation — Method of applying — Powerful action of small battery 
— Mr. Hamilton's observations — Value of galvanism and electricity — Use of, in para- 
lysis of the muscles of the face— Paralysis from disease of the arterial system — Case 
of, by Dr. Graves — Diagnosis of this affection — Pathology of Pott's gangrene — Du- 
puytren's mode of treatment ...... 327 

LECTURE XXXII. 

Paralysis from arterial disease — Singular cases of, by Rostan — Diagnosis of paralysis 
from arterial obstruction — Magnetism, use and action of — Effect of magnetism in 
disease — Result of trials in the Meath Hospital — Paraplegia — Mechanical hypere- 
mia — Occurrence without disease of the cord or vertebra?— Cases by Mr. Stanley — 
Effects on urine by division of the spinal cord — Ammoniacal urine — Caries of the 
vertebra? — Diagnosis of paralysis with disease of the kidney — Prognosis in para- 
plegia — [Dr. Graves's views and cases of paraplegia — A sequence of fever — Means 
of prevention and cure — Local injury to a nerve causing partial paralysis] 335 

LECTURE XXXII L 

Sudden paralysis from abscess of the brain — Curious case of paralysis without effusion 
— Previous symptoms of — Demonstration of the cellular tissue of the brain — Com- 
pressibility of the brain — Inaccuracy of the opinions of Drs. Abercrombie and Clut- 
terbuck — Pathological states — Arachnitis without delirium — Traumatic apoplexy — 
Case of paralysis of the portio dura — Peculiar appearance of the affected side of the 
face — Use of the electro-puncturation — Bad effects from — Mechanical support of 
paralysed parts — Neuroses, active and passive — General pathology of— Principles of 
diagnosis — Case of neuralgic liver — Neurosis from moral causes . 350 

LECTURE XXXIV. 

Principles of treatment of neuralgic affections — Connection with organic disease — 
Neuralgia of the liver — Treatment — Hemicrania — Treatment — Use of iron, quinine, 
and opium — Endermic method of using opium — Tic douloureux— Opinions of Sir C. 
Bell — Remarkable case related by — Inflammation of frontal sinuses — Violent symp- 
toms — Mr. Crampton's treatment — Affections of the fifth and seventh nerves in 
cases of cerebral disease — Neuralgia of the side— Researches of Lombard and Brande 
on the effect of nitrate of silver — Injury to the skin. — [Appropriateness of the term 
neuralgia. — This disease may be caused by inflammation of the nervous sheath — 
Origin of neuralgia sometimes in the nervous centres — Change in the state of the 
nerves themselves and in their extremities — Diagnosis of neuralgia — Nerves and 
regions chiefly affected with neuralgia — the fifth pair and the dorsal and sacral nerves 
— Varieties of neuralgia specified — Dorsal or intercostal neuralgia mistaken for irrita- 
tion of the spinal cord — Its seat, symptoms, and diagnosis — Ganglionic and visceral 
neuralgia — Treatment of neuralgia] ..... 360 

LECTURE XXXV. 

Scrofula; former opinions on — White and red capillaries— Division of the system into 
red and white tissues — Vascularity of the white tissues — Dr. Graves's views of the 
lymphatics — Analogies of lymphatics and veins — Meckel, Cruikshank, and Magen- 
die's opinions on — Relations of the circulating and nervous systems — Vitality of 
serous membranes — Reproductive power of white parts — White blood and white 
tissues more prevalent in women than men — White tissue more liable to cancre, &c. 
— Analogy of the white parts with cold-blooded animals — Increased sensibility of 
white tissues — True nature of the scrofulous diathesis — Reference to arrest of 
development — Explanation of its phenomena — [Connection between phthisis and 



CONTENTS. 



13 



scrofula not so evident — Causes of scrofula — Damp and impure air the chief cause — 
Physiognomical traits of scrofula — Treatment, general and local — Scrofulous tumours ; 
applications to — Enumeration of tissues and organs the seat of scrofulous disease 
— Modifications of inflammation by scrofulous diathesis — Principles on which 
the treatment is based — Depletion not prohibited — Mercurials, how to be used— Other 
alteratives — Tonics and narcotics] . . . . . 385 

LECTURE XXXVI. 

Fever — General considerations on — Erroneous modes of investigation — Importance of 
the labours of French pathologists — complication of fever with local disease — Primary 
and secondary fevers — Relation of, to local changes— tendency to spontaneous termi- 
nation — Principles of treatment — Errors of Brown and Broussais — Researches of 
M M. Gaspard and Magendie — Their pathological conclusions — Importance of the 
knowledge of secondary lesions — Effect in preventing crisis — Treatment — Humoral- 
ism and solidism ....... 407 

LECTURE XXXVII. 

Intermittent fever — Definition and character of — Phenomena of the paroxysm — Cold 
stage — Internal congestions — ^Pathology of — Hot stage — Ague not a simple fever — 
Affections of various viscera — Theory of Broussais — Effects of bark, quinine, &c — 
Modus operandi of ....... 417 

LECTURE XXXVIII. 

Intermittent fever — Symptoms — Occasional irregularity of the paroxysms — Convulsive 
motions of the foetus in a pregnant woman during ague — Exciting causes of ague — 
Treatment— Complication with other diseases — Importance of careful investigation 
— Visceral lesion, how far contra-indicating the use of bark — Bark almost a specific 
in ague — Large doses of quinine in ague — Rapidity of its operations in some cases 
— Fowler's solution of arsenic — Prussian blue — Its advantages . . 4&5 

LECTURE XXXIX. 

Use of quinine — Disease not a simple increase or decrease of vitality — Barks a specific 
in ague — To be given in the period of apyrexia — Large doses at considerable inter- 
vals — Arsenic followed by dyspepsia — Mercury, its effects in ague — Treatment dur- 
ing the paroxysms — Dover's powder, heat, laudanum, carbonate of ammonia — 
Pressure on large arteries to arrest the cold stage — Used in a case of hydrophobia with 
temporary relief— Gastric-intermittent — Endermic mode of using quinine — Bleeding 
in the cold stage — Generally with safety and advantage — Supervention of other dis- 
eases — [Miasm not a cause of intermittent fever — Visceral obstruction and inflam- 
mation relieved by venesection in the hot stage and in the interval — Cold bathing — 
Mercury — Modifying influence of climate — Effects of arsenic — Case of malignant in- 
termittent — Little variety of tonics necessary for the cure of intermittents] 434 

LECTURE XL. 

Continued fever — Varieties of fever infinite — Typhous fever— Symptoms of typhus — 
Petechia?, sign of typhoid character — State of the tongue various — Progress of the 
disease — Typhus produced by injection of putrid substances into the veins — Hemor- 
rhage from the intestines, &c. — Opinions on fever — Prognosis— Phenomena arising 
from each system — Jaundice an unfavourable sign . . . 454 

LECTURE XLI. 

Nervous symptoms in typhus — Uncertainty of development — Opinions of Dr. Clutter- 
buck — Unfrequency of lesions of the brain in typhus — Occurrence of all nervous 
symptoms, independent of any appreciable symptoms of the brain — Nature and 
treatment of headache in fever — Delirium, researches of Louis on — Its treatment in 
early and advanced stages of fever — Pathological state of the brain in delirium — Use 
of wine and opium — Dr. Graves's remarks on — Nature of adynamia — Principles of 
treatment of the local inflammations in fever — Errors of the school of Broussais on 
this point — Use of stimulants at certaiu stages . . . . 461 

LECTURE XLII. 

Opium in fever — Dr. Latham's opinion on — Symptoms for the exhibition of opium — 
Affection of the sensorium in fever — Adynamia, consequence of fever — Direct ady- 
namia — Indirect adynamia — Treatment of — Stimulants in fever — Dr. Grant's notions 
of fever — Symptoms of typhus — Catarrh of fever — Opinions of Andral, Louis, and 
Laehnec — Bronchitis with fever — Increase of rales on decrease of disease — Affection 
of the gastro-intestinal mucous surface — Symptoms of Pneumonia and bronchitis — 



14 



CONTENTS. 



Pneumonia of fever— Symptomatic affections of the respiratory system in fever — 
Sympathy between the left lung and stomach — Phthisis, consequent of fever 471 

LECTURE XLII. 

Peripneumonie des agonizans of Laennec — Congestion of the lungs from position — 
Avenbrugger's opinions on — Precaution of Boyer — Importance of position in typhus 
— Treatment of catarrh and pneumonia in typhus — Principles of treatment — Manage- 
ment of excessive secretion — Employment of emetics — Use of sulphate of quinine 
and opium in injections — Typhoid pneumonia — Gastric symptoms in fever — Brous- 
sais' physiological theory — Brown's sthenia and asthenia — Remarks of the physiologi- 
cal school — Different treatments of fever .... 482 

LECTURE XLIV. 

Different lesions in typhous fever — Absence of gastroenteric symptoms — Cases by Bouil- 
laud, Andral, Louis, &c. — Andral's arrangement of fevers — Louis's opinion on the 
anatomical character of fever — Analogy of typhus with small-pox — Absence of pain 
in enteritis — Means for diagnosis — Variety of disease in serous tissues from typhus 
— Treatment of the digestive symptoms of typhus — Hiccup — Tympanites in fever, 
treatment of — General treatment of fever — Conclusion of the course . 493 



CONTENTS 

TO BELL'S L'ECTURES. 

LECTURE I. 

Typhous fever not essentially different from typhoid fever — The general symptoms and 
organic changes nearly the same in the two diseases — Symptoms illustrative of func- 
tional lesions in the first stage of typhus — Indications thence resulting for selection of 
remedial means — Resemblance between typhus and poisoning — Cold baths — Emetics 
— Enema — Purgatives — Venesection — Modification of treatment by the constitution, 
prior habits and exposure of the patient—To increase the action of the depurating 
organs — Changes of treatment with difference of stage of the fever — Employment of 
stimulants in typhous fever — Indication for their use furnished by the state of the heart 
— Dr. Stokes's cases and observations — Caution in the general inference from hospital 
practice — Tartar emetic practice in typhus — Rasori's views and cases — Dr. Graves's 
opinion and cases — Utility of tartar emetic by the mouth and in enema, and in the 
form of ointment — Thirst, relief of — Not to forget the recuperative power of nature 
as shown by cures without medicine ..... 507 

LECTURE II. 

Congestive fever — Is not a new disease — Restricted notions on the subject — Congestion 
an effect of irregular circulation — Is symptomatic of various nervous disorders — Con- 
gestion associated with intermittent, remittent, and typhous fevers — Each of these in 
one of its stages is complicated with congestion — May be associated with inflam- 
mation, but not dependent on it — Same of congestion and hemorrhage — What is the 
actual state of the sanguiferous system in congestion — Capillaries act an important 
part in congestion, — and they in turn are modified by the state of the nervous system 
— Excellent descriptions of congestive intermittent and remittent fevers by European 
writers — Torti — Alibert — Senac, his views and cases — Lind, his cases — Clark, his 
cases and description of Bengal fever — Johnson on the state of the viscera — Shields 
on the Batavia fever ....... 525 

LECTURE III. 

Congestive fever— Lesions of the organs, — How far observed in this fever — Dr. Bailly's 
observations and cases at Rome — Gastro-enteritis, arachnitis, and splenitis, common 
accompaniments of malignant or congestive fever — Importance of separating the 
symptoms, and their periodical recurrence, which depend on the nervous system, from 
those which are the product of inflammation in some organ — Great congestion and 
red 

ness of the gastro-intestinal mucous membrane and gastro-enteritis may remain 
after the periodical fever is removed. — Congestion of an organ, the effect of nervous 
irritation, may react on the nervous system and complicate the symptoms. — Probability 
of the primary cause of the nervous irritation being a disorder and sometimes phlo- 
gosis of the alimentary canal — Predominance of the nervous system in the produc- 
tion of the paroxysm of fever — Tendency to intermission in the functions of the 
nervous system — Periodicity depends on this system — Complications of the fever by 



CONTENTS. 



15 



inflammation of an organ — Double nature of intermittent fever — constituting a 
neurosthenia. — Antagonism of the nervous and vascular systems . . 539 

LECTURE IV. 

Pathology of congestive fever continued — Congestion caused by nervous irritation 
may disappear with removal of its cause — Predisposition of particular organs to be 
affected — Inflammation aggravated by every febrile exacerbation — Nervous sys- 
tem excited or oppressed by its appropriate agents, irrespective of vascular changes 
— Conjunction of fever with inflammation of an organ — the two diseases independent 
of each other — Continually to have the nervous system in our mind when studying 
fever—Diagnosis of pernicious intermittent or congestive fever — Appearance of the 
patient — Great and sudden changes in — Uncertainty of symptoms furnished by the 
tongue, and discharges from the stomach and bowels — Urine — Pulse— Secretions — 
Prognosis — Death during the hot stage of reaction, and commonly in the latter part of 
the day or in the night — Greatest violence on even days — Unfavourable signs — Re- 
covery after seemingly fatal signs — Termination of the fever at fixed periods — Aver- 
age duration of a case of fever 553 

LECTURE V. 

Treatment of congestive fever — Diversified states of the organs requiring variety of 
remedies — Congestion the product of nervous irritation ; may be associated with inflam- 
mation — In the first case, the remedies are to be addressed to the nervous system — In 
the second, to produce organic changes of tissue — Common features of congestive fever 
— Early attention required to the forming stage — Repose and abstinence from all 
stimulants important preparatives — Stage of reaction less marked than in an exacerba- 
tion of common fever — Partial remission and renewal of fever — Subsidence and com- 
plete interval followed by a fresh and violent paroxysm — Commentaries on the 
common modes of treatment — Necessity of attention to the periodical character of the 
fever, and the diurnal period required for completion of the direct effects even of medi- 
cines — Prior habits and exposure of the patient — Treatment required during the stage 
of depression, chill, coma, &c. — Its limited duration and common termination if left 
to itself— Sydenham's views — Two modes of treatment in the first stage- 1 — the power- 
fully stimulating, and the depleting by blood-letting — The true state of the nervous 
system at this time is that of irritation — Soothing and sedative measures preferable 
in this stage — Opium, its good effects in the comatose and cold stage of fever — 

^ f '€ase . . . ' . . . 586 

LECTURE VI. 

Treatment of congestive fever continued — Proposal to equalise the circulation by the 
abstraction of accumulated and congested blood is based on too physical a view — 
The other alleged indication, to remove venous blood deleterious to the organs is not 
physiological — Experiments of Edwards — Congestion an effect and a symptom, not 
a cause — Blood-letting not called for in the premises — Cases— Reaction after bleeding 
in the depressed stage an evidence of remaining vital power, and not of the efficacy 
of the remedy. — Blood-letting useful in congestive fever during the febrile reaction, 
if there is inflammation of some organ — Modes of abstracting blood — Topical, as 
by leeches and cups with scarificators — Dry cupping — Immediate effects of blood- 
letting — Its mode of action — Fallacy of judging from symptoms of reaction — Necessity 
of removal of irritants from the alimentary canal with reference still to the phlogosis 
of the mucous membrane — Milder means to be preferred — Enemata — Emetics when 
indicated — Emetics and dry cupping — Purgatives — calomel, castor oil, and spirits 
of turpentine — Action of the turpentine — Treatment in the exacerbation of conges- 
tive fever — High febrile reaction sometimes rapidly subsides into extreme debility — 
Blood-letting — cold affusion — cold drinks, simple and acidulated, or slightly bitter — 
cold enemata — Purgatives to be avoided at this time — Saline preparations largely 
diluted in simple fluid, and taken as a drink — Secretions restored by these means 580 

LECTURE VII. 

Treatment of congestive fever concluded — A remission or intermission being established 
our main reliance is on quinine — Purgatives and blisters inefficient, sometimes in- 
jurious — Mode of action of quinine, — sedative — Large doses of quinine required at 
this time — Authorities and cases in favour of this practice. Calomel and tartar 
emetic. — Analysis of the operation of calomel: it is at first and mainly a sedative — as 
such acts on the secretions through the nervous and capillary systems. It is adapted 
to diseases of high action and is injurious when assimilation is imperfect and its in- 



16 CONTENTS. 

terruption dangerous, as in scrofula, consumption, scurvy. Is regarded by Annesly 
as an anti-periodic — Harmony between calomel and quinine, — Advantages from giving 
them in alternation — Tartar emetic, its febrifuge and anti-periodic properties. — Second- 
ary congestive fever .......... 591 

LECTURE VIII. 

Blood-letting and quinine successfully employed by Dr. Bailly, and in the Roman hos- 
pital — Summary of the curative course in congestive fever — Calomel,— its operation 
on the nerves and capillaries, and on the secretory and nutritive organs — Cures in- 
flammation by attacking nutrition — Poisonous effects of mercury when long conti- 
nued — Clinical inference — Congestive typhus — Armstrong's cases — Their resemblance 
to malignant tertian fever — Armstrong's treatment. — Fallacy of belief respecting mer- 
curial ptyalism — Natural or spontaneous termination of remittent fever — Tantini's 
cases ............. 606 

LECTURE IX. 

Application of the pathology of congestive fever to that of cholera in its various forms 
— Cholera infantum, outlines of treatment of. — Phlegmasia? of the skin. — Different 
genera of — Hyperemia — Exanthemata? — Erysipelas, — its treatment. Eoseola, — its 
varieties and treatment. Exanthematous or eruptive fevers proper — measles, scarla- 
tina, and small-pox — Their precursory fever and first eruption. Alleged differential 
diagnosis. Sequelae of eruptive fevers — Sameness of the organs affected in all of them 
— first, and chiefly, the air-passages ; then the digestive mucous and the serous mem- 
branes and the brain — Skin and pulmonary mucous membrane, the tissues which 
chiefly suffer Treatment of the eruptive fevers — Must vary with the changing cha- 
racter of the epidemic visitation — Explanation of different modes of practice — that 
in the inflammatory scarlatina — Measures required in the congested and typhoid va- 
riety . . . . ' .' 618 

LECTURE X. 

Rheumatism, acute and chronic — Defined after the parts affected — Acute articular rheu- 
matism — Internal organs attacked — Symptoms of acute rheumatism — Is a true arthri- 
tis — Causes, exciting and predisposing — Congenital predisposition — Treatment, at 
first decidedly antiphlogistic — blood-letting, tartar emetic, colchicum, purgatives — 
Opium, when proper — Calomel most useful after an abatement of phlogosis — Its use 
not to be pushed so as to cause salivation — Warm-bath ; opium ; quinine — Acute 
rheumatism of the bowels — Pericarditis and endocarditis ; their frequency as varieties 
of rheumatism ; their symptoms . •• 633 

LECTURE XI. 

The treatment of pericarditis and endocarditis — Other varieties of the disease ; pleuro- 
dynia, diaphragmitis, &c. — Regimen — Chronic Rheumatism — Same order of parts 
affected, and similar morbid products as in the acute forms — Two divisions, the active 
and passive — Treatment : general and local — Necessity of proper regimen — Varies 
with the case — Different remedies which have been used—Local applications — Dia- 
phoretics — Sulphurous waters — Hygienic course 645 

LECTURE XII. 

Chronic Laryngitis, its synonymes — Seat of the disease — Structural changes — Appli- 
cableness of the title — laryngeal phthisis. Large proportion of ulcerations in the 
epiglottis, larynx, and trachea in phthisical subjects — Symptoms : sensations, voice, 
aphonia, cough, breathing — Different species of chronic laryngitis, — a knowledge of, 
necessary for prognosis and treatment — Examination of the fauces and pharynx — 
To determine the state of the lungs : auscultation, percussion, and expectorated 
matter — Duration of the disease — Causes: age, sex, prior disease, vocal strain, 
atmospherical vicissitudes, habits — Treatment : rest of the vocal apparatus, anti- 
phlogistics, counter-irritants, narcotics, mercurials, iodine, sarsaparilla, balsam 
of copaiva, blue mass and syrup of sarsaparilla, sulphurous waters — Topical reme- 
dies : inhalation of simple and stimulating vapours, caustic to the parts, attention 
to anginose complication — Syphilitic chronic laryngitis : mercurials, sarsaparilla, 
iodine — Tracheotomy, when proper — Prevention of the disease — Clergymen, — rules 
for their guidance— Uniform temperature of air — Jeffray's Respirator — Change of 
climate 657 



LECTURES 

0~S THE 

THEORY AND PRACTICE OF MEDICINE. 



LECTURE I. 

GENERAL OBSERVATIONS. 

Gentlemen : — You may have often heard that the approaches 
to science are rugged and uninteresting, and some of you have 
perhaps experienced the truth of the remark. Hence the custom 
of delivering an introductory lecture, in order to lay before the 
young mind, when first entering on each path of knowledge, the 
objects, the results, the attained good, and the hoped-for glory of 
the pursuit. These are to be displayed with clearness and with 
truth, yet it is obvious that much of the effect of such a lecture 
must depend on the nature of the subject and the judgment of the 
speaker; and it is well when the exalted nature of the one is 
attainable by the capabilities of the other. Such a lecture, then, 
should be an earnest lesson on the objects, the pleasures, and the 
advantages of that science, of which the course is destined to treat; 
its history, its true mode of study, its interest, actual state, and 
future prospects, may all form legitimate subjects, and when thus 
rightly viewed, an introductory lecture, so far from being a mere 
ornamental appendage, may become a most important part of the 
course. 

With these views let us approach our subject, the theory and 
practice of medicine. Let us contemplate that study and that pro- 
fession, which, venerable by all antiquity, yet in itself is " ever 
new." Even in its infancy, when the world was in darkness, was 
medicine a glorious science when compared with its cotemporaries, 
and its first professors were ennobled and exalted by its influence. 
As their mantles descended through a long line of illustrious suc- 
cessors, we see medicine progressively expanding, and even when 
the night of barbarism hung gloomily over the earth, we see its 
genius triumphing over the surrounding darkness, and shining in 

3 



18 



STOKES'S THEORY AND PRACTICE. 



the east as a beacon to the shipwrecked mind of man ; and I trust 
that I shall be able to prove to you, that, in our own time, when 
the human mind has made such astonishing advances, medicine has 
kept pace with her sister sciences, and it is a gratifying reflection 
to think, that, among the most distinguished promoters of the col- 
lateral sciences, physicians have ever held a commanding rank, 
thus proving themselves foremost in knowledge, as they have ever 
been in philanthropy, in private and public charity, and in all good 
will to man. 

It is scarcely necessary to allude to the title of this course of 
lectures, further than to remark, that, however different they may 
be in name, it is yet impossible to draw the line of distinction 
between the theory and the practice of medicine. If medicine 
were merely the knowledge of a number of empirical remedies for 
particular symptoms, given without our inquiring into their mode 
of action, or any acquaintance with the dependence of one func- 
tion, or one viscus, on another, of any knowledge, in short, of 
physiology in the healthy or diseased state, then we might have a 
practice of medicine independent of what is called its theory. But 
medicine now holds a higher place, and much of its improvement 
is traceable to our advances in physiological and pathological 
science. Thus to treat, or teach, the treatment of a disease, we 
must know the healthy function of the organ, or organs, the history 
of development, the influence of other organic systems, the changes 
produced by disease, and, as far as possible, the action of all 
external or internal agents on the viscera. But this is the theory 
of medicine. 

For example, let us suppose that we are called either to treat or 
to teach the treatment of a case of enlarged liver. Let me here 
remark, that in selecting this case I do not wish you to suppose 
that I am one of what might be called the hepatic school of medi- 
cine, in which the existence of almost every organ, except the 
liver, seems to be forgotten, and of which the creed seems to be, 
that there is but one viscus, the liver, one source of disease, biliary 
derangement, and one cure, mercury ; a creed which, though not 
enforced and defended by the sword, has lost perhaps as much of 
human life as others whose history is written in letters of blood.* 
But no one can doubt the importance of the organ, and I have 
taken it to illustrate the connection between the theory and the 
practice of medicine. 

You detect an enlarged liver ; you are called to cure the dis- 
ease : — 

1st. You must be aware of the healthy state of the organ, and 
of its healthy functions, as shown by the volume, sensibility, influ- 

* [I wish it could be said that we in the United States are not amenable to this 
censure. But, alas ! the spoonful doses of calomel, and pills with calomel for 
their basis by the dozens, are, or have been, prescriptions which have cast a stigma 
on too many American practitioners, who see but one disease,— that of the 
liver. — B.] 



GENERAL OBSERVATIONS. 



19 



ence on digestion, and the healty state of the secretion. You must 
know all these, as it is by the departure from these conditions that 
you recognise this disease at all. — But this is the theory of medicine. 

2dly. You must know the history of its development, because 
there is a period of life when the natural state of the liver is in a 
greatly enlarged condition, and this may continue even to adult 
life, and produce an enlarged liver, not the result of disease but 
the arrest of development, and the question will arise as to whether 
the case before you is an example of this, or of recent and actual 
disease. The whole treatment turns on this. — Yet this is the theory 
of medicine. 

Sdly. You must know the influence of other organic systems. 
An enlarged liver may be produced mechanically by obstructions 
in the lungs or in the heart ; it may be produced from the sympa- 
thetic irritation of a duodenitis, or be the result of original disease 
in its own structure. All these circumstances must be known and 
taken into account. If it be merely obstruction in the venae cavae 
hepaticae the ordinary treatment will not answer ; if there be duo- 
denitis we must modify our treatment, and so on. We must know 
these things; we must know how to recognise these diseases before 
we can prescribe or practise successfully. All this is that part of 
the theory of medicine called pathology, or the physiology of the 
diseased body. 

4thly. You must know the effects of disease on the liver itself. 
Some of these are removable by art, others are totally incurable. 
You must know these in order to determine on the probability of 
their existence. 

5thly and lastly. You must know the influence of remedial 
agents on the liver and the adjacent organs. You must be fami- 
liar with the effects of stimulation of the mucous surfaces of the 
stomach and duodenum. Then, indeed, and not till then, will you 
be qualified to treat the case with judgment and success. The 
same remarks, I need scarcely add, will be found applicable to the 
diseases of each viscus in the body. 

The objects of medicine, gentlemen, are twofold ; first, to cure 
disease, no matter where seated or how produced ; and secondly, 
to relieve bodily suffering in cases where a cure is impossible. Its 
great end is to prolong life, and to diminish the bodily evils which 
result from the infirmities of our nature and other circumstances. 
Some of you may ask, where then is the distinction between medi- 
cine and surgery 1 In truth, there is no distinction in reality, and 
there should be none in theory. The human constitution is one; — 
there is no division of it into a medical and surgical domain ; the 
same laws and the same principles of treatment apply to the cure 
of a fractured bone and the cicatrization of an internal ulcer. 
Unlike the corporations of medicine and surgery, the supposed 
purely medical and purely surgical parts of the body live in excel- 
lent harmony. Here, then, there is no division, no jealousy, no 
separation of interests. 



20 STOKES'S THEORY AND PRACTICE. 



I am by no means prepared to deny that advantages may arise 
from a practitioner devoting himself to this or that branch of his 
profession ; but if he seeks for eminence, he will first educate 
himself generally. Let him attain extended views of pathological 
medicine ; let him make himself master of the actual state of the 
science, and then he will find that there is not a single fact or law 
with which he has become acquainted that will not have its bear- 
ing on his particular pursuit. It is in the education of medical 
men that the ruinous effects of the division of the professions of 
medicine and surgery are most perceived : and I feel convinced 
that, of the two, the surgical student is the greater sufferer, be- 
cause his views of pathology are injured. All the great laws in 
pathology are drawn from the consideration of visceral disease; yet 
the attention of the surgical student is diverted from this, and 
directed to what, I will say, can never elevate him in the ranks of 
science. He is taught anatomy, and what is called surgical disease, 
but he is kept ignorant, by this wretched system, of the great part 
of his profession, until he comes to practise, when, if he has a mind 
fitted for observation, he will find, that for one ^dislocation there 
will be hundreds of visceral diseases; and he will discover what 
was concealed from him during his pupilage, thai many, many 
more die of what are called ■ medical than surgical diseases. 
During the late war, more men in the British navy died of fever 
than of all other causes — including the sword. But, I rejoice to 
say, in Dublin the exclusive system of education is fast wearing 
way, and one of the many excellences of our national school of 
medicine is the instruction in general pathology. There are few 
schools of medicine where now a more enlarged and liberal spirit 
of education exists. 

In the study of your profession, gentlemen, let me warn you not 
to allow yourselves to be misled by the idea that surgery and me- 
dicine are different in their nature. The mere surgeon, or the mere 
physician, only knows half of his profession. Reckless of human 
life, he may practise the healing art as a trade, but he never can 
know it as a science. But, as there are infinitely more cases of 
what are termed medical than surgical disease, it is plain, that the 
surgeon, ignorant of medicine, will far exceed the physician igno- 
rant of surgery, in the extent of his malpractice. I have long 
observed the ruinous system which has been pursued by teachers, 
as connected with this subject. The pupil was taught to consider, 
that if he was a skilful anatomist, if he understood the routine 
surgery of an hospital, and had carefully studied certain works on 
surgery, and some obsolete books of pathology, he was thereby 
prepared, in the language of the schools, to go forth to teach and 
practise the art and mystery of medicine in general. Now, all this 
was wrong. You may be profound anatomists and be bad surgeons, 
and worse physicians ; you may have by heart the writings of Pott 
and Dessault, of Hunter and Thompson, and be totally incapable of 
treating a simple or complicated fever, or a case of visceral disease. 



GENERAL OBSERVATIONS. 



21 



But it is not necessary to say more. Society demands that the 
old system of a division in education should be abolished ; and 
ere long, I even trust to see a fusion of the profession, when much 
of the present evils must cease, when medical men shall have a 
common centre, from which they will receive a common impulse ; 
when their efforts shall be solely directed to the increase of medical 
science, and the political and moral exaltation of their profession ; 
and last, yet not least, when the ingenuous pupil shall not be led 
astray ; when we shall not be told by one teacher to despise this, 
and by another to neglect that part of his profession ; but, having 
the whole of the noble science of medicine thrown open to him, his 
mind, unwarped by prejudice, unfettered by fear, shall be permitted 
to take that right view of his pursuit, that alone can lead him, and 
assuredly will lead him, to the honours and success which truth 
bestows on all its votaries. 

I have said, that the exclusive system of education had singularly 
diminished in Dublin. Indeed, our national school has earned great 
reputation for general pathology ; and, from a long and cordial 
intercourse with the class of Dublin, I will affirm, that there are 
few places where we can see such zeal, talent, and thirst for know- 
ledge among the students. As an Irishman, addressing my own 
countrymen, let me congratulate you on the fame the Dublin 
School of Medicine and Surgery has now acquired, and is every 
day acquiring; and when the strength of Irish talent, aided by the 
proper working of our unrivaled institutions, is brought into play, 
may we not anticipate a still more glorious result 1 This reflection 
has often cheered me, that within the last few years there has been 
a greater stimulus infused into the science and literature of this 
country. Amid the ungenial influences of political excitement, and 
the animosities of party, how gladly should we contemplate the 
advance of what will prove an honour to our national character, 
and an advantage to mankind. It is like the growth of the coral 
into rocks and fertile islands, though surrounded by the strife and 
waste of waters. Our scientific societies have multiplied ; our 
periodical literature, the want of which furnished so fruitful a theme 
for cavil, has been extended so as to afford a wholesome and vigor- 
ous supply in the varied departments of literature and science ; and 
our monthly and quarterly publications are taking their proper 
place among the ranks of British journals. When we turn to 
works of a more permanent kind, we also see cause for satisfaction. 
Many most important works in anatomy, surgical pathology, 
physiological medicine, and midwifery, have lately issued from the 
Irish press ; and the Irish contributions to the Cyclopaedia of Prac- 
tical Medicine are allowed on all hands to give to that work no 
mean portion of its value. 

There are few more wholesome exercises for the mind, few so 
necessary and so useful as the comparison of the actual state of 
any science with its advance and character at a former period ; 
and it is in this, most chiefly, that the value of what is called the 

3* 



22 



STOKES'S THEORY AND PRACTICE. 



history of medicine consists. We study it then, not as a matter of 
antiquarian research, of learned curiosity, but as the picture of the 
human mind, now on the right path, now misled by error, yet still 
struggling onward ; as the record of a dear-bought experience, and 
a beacon to warn us of the rocks and shoals that beset its future 
progress unto truth. To analyse the actual state of medical science, 
to show you all that has been done within a little time, to display 
all old pretensions to the character of a true and thrice noble science, 
would far exhaust my capabilities and your patience. Let it suffice 
to contemplate the improvement considered generally, and the means 
by which that improvement has been attained. 

It is an error too generally received, that medicine owes all its 
advances to the researches of modern times. Far be it from me to 
undervalue these, but I believe that the opinion I have alluded to 
is wrong, and is perhaps kept alive by our own vanity ; for by a 
specious deception we often take to ourselves the honours and dis- 
tinctions of the time we live in. The truth is, that medicine, like 
many other of the sister sciences, has been long steadily advancing, 
and the flippant every day remarks that the inductive system (that 
is, the observation of facts and the embodying of those conclusions 
that legitimately flow from them) has been only introduced into 
medicine in our time ; and that our predecessors in medicine put 
theory first and fact second in their medical philosophy, are " as 
false as dicers 7 oaths" Have the authors and teachers who are so 
fond of decrying the medicine of a former day, at a time when they 
are (perhaps innocently) making use of its facts and observations 
— have they read the writings of the father of medicine 1 Have 
they studied that/ 4 aureum opus" so well called from its lustre, its 
purity, and its surpassing value? Was Avicenna a mere theorist ? 
Did Morgagni observe no facts, nor truly record them, even at the 
expense of his medical reputation 1 Is there no induction in Bag- 
livi 1 W as HaHer unacquainted with the method of experiment and 
induction? Or is the discoverer of the circulation of the blood, the 
good, the great, the injured, but the immortal Harvey, forgotten ? 
Where do they place Boerhaave ? and shall the name of Sydenham 
go down with his ashes to oblivion 1 

The true state of the case is, that medicine, in its present ad- 
vanced state, only represents the improvement in other branches of 
human knowledge, all of which are so intimately linked together, 
that, although their extremes be far removed, there is a point where 
all are reciprocally cause and effect; so that if we take any one of 
them, it is easy to show its intimate bearings with, and importance 
to, all the rest. We have been long advancing in medicine; and 
though I admit most fully the vast strides which have been made, 
still I must here declare my firm conviction, that the study of the 
older authors is too much neglected, and that in them you will find 
a treasury of knowledge, much of which you may think to be the 
production of modern times. 

If the writings of the ancient authors only contained a small 



GENERAL OBSERVATIONS. 



23 



portion of the information with which they abound, it would be a 
sufficient stimulus to their study ; to reflect that it is in them, in 
the medical writings of the ancients, that the germs of the induc- 
tive philosophy are first to be found. It is, then, in the old regions 
of medicine that we find the fountains of that mighty river, which, 
for two thousand years, has fertilized the earth, and made man its 
lord. Had the progress of man not been retarded by the ignorance 
which is the child and servant of barbaric despotism, an earlier 
Newton might have enlightened the earth, an earlier Laplace have 
measured the heavens, or a Cuvier declared the glories of a past 
and present creation. The mind of man would have burst its chains, 
and ages ago have formed that holy alliance with knowledge and 
her first-born, liberty, which now is its safeguard and its glory. I 
repeat it, in the writings of Hippocrates you will find the principles 
of the inductive philosophy. A physician showed Bacon the road 
to immortality. 

We find that there is in the mind of man a tendency to reverse 
the true mode of reasoning, and to seek for a principle before it has 
observed facts, and this was the cause of the retardation of medicine, 
as well as of all other sciences. Hence the various schools, from 
Pythagoras to Cullen or Brown, in our day. But a slow, though 
sure, revolution was long going forward ; and I believe that Cullen 
and Brown were even behiiid the actual state of medicine in their 
time. Physicians turned disgusted from the war of words and 
doubt, to seek in tangible objects the certainty which these only 
can produce ; in a word, they began to follow the Baconian system 
more generally. They reverted to the instructions of Hippocrates, 
and from that period our modern improvement may date. They 
turned their attention to the examination of those changes which 
disease produces on the human body, and connected these with 
the symptoms observed during life. And what has been the result 
of this? 

1st. The accumulation of an enormous number of facts, relative 
to the changes of organs produced by disease. 

2d. The connection of a vast number of these changes with, 
particular symptoms, and hence the advance in diagnosis. 

3d. The establishment of the true value of symptomatology, and 
the verification of that all-important fact, that opposite states and 
organs may produce similar symptoms. 

4th. The knowledge of the vast class of latent diseases ; in other 
words, diseases which exist without influencing the phenomena of 
animal life, or, in some cases, the phenomena of both animal and 
organic life. Diseases, either without symptoms at all, or only 
with such as previously were not supposed capable of leading to 
their detection. You know that the phenomena of life are divided 
into two classes, viz., those of organic or vegetable life, such as 
nutrition, circulation, absorption, respiration, secretion. While 
those of animal life, or the life of relation (so called from its being 
the source of our connection with surrounding bodies), are the 



24 



STOKES'S THEORY AND PRACTICE. 



senses, the phenomena of mind, and muscular motion. The one 
life seems more under the influence of the ganglionic, and the 
other under that of the cerebro-spinal system of nerves. 

As some of the junior part of the class may not have accurate 
ideas as to the meaning of symptoms, I may state that disease is 
recognised by signs and symptoms. 

By signs, we mean those mechanical alterations, produced by 
disease, in the conditions of parts, which are recognisable to the 
external senses of touch, sight, and hearing ; changes in appear- 
ance, volume, shape, resistance, peculiarities of feel, and the pro- 
duction of sounds. We may make a diagnosis by signs alone. 
Take, for example, a case of tympanitis. The abdomen is promi- 
nent, enlarged, circular, elastic, and sounding like a drum when 
struck. Thus we learn that the belly is distended by air. 

Now, symptoms are totally different ; they consist in certain 
changes produced in functions ; and these functional changes are 
to be considered in a threefold manner: — 

1st. Changes in the functions of the part itself. 

2d. Changes in the phenomena of organic life. 

3d. Changes in the phenomena of animal life. 

Let us take, for example, a case of inflammation of the stomach. 
We have, first, changes in its own functions — morbid sensibility, 
vomiting, thirst, anorexia. In the next place, we have changes in 
the functions of organic life — fever, from the action on the circu- 
lating system ; hurried respiration, and cough, and hiccup, from 
the action on the respiratory system ; jaundice, from its action on 
the biliary system ; suppression of the secretion of the skin, 
kidneys, &c. All these, you observe, are lesions of the functions 
of organic life. 

But we may have other symptoms ; prostration, headache, deli- 
rium, convulsions ; these are lesions of the life of relation, or 
animal life. 

Now, in many cases, we have to combine these sources of 
knowledge to form a correct diagnosis. Take, for example, a case 
of hepatitis. 

The patient has had pains in the hepatic region, fever, jaundice, 
hurried breathing, tenderness. After some time he has a tumour ; 
the side dilated; the hypochondrium dull on percussion. Well, 
the signs point out an enlargement of the liver ; the symptoms, 
that the cause of that enlargement was an acute hepatitis. 

In general, we may state, that signs only declare the actually 
existing mechanical condition, while symptoms, either present or 
past, point out the cause of the change, whatever it may be. Both 
must be studied together ; but you will learn more from symptoms 
without signs, than from signs without symptoms. But to return 
to the results of the improved method of investigation. 

Great light was thrown on fever in general ; and it is, I believe, 
quite true, that all the advances which we have made in the know- 
ledge of fever, are due to the prosecution of pathological anatomy. 



GENERAL OBSERVATIONS. 



25 



Almost all of what we may call our general knowledge of fever, is 
due to Hippocrates ; but anatomy has revealed its effects, its com- 
plications ; and the all-important fact, that the cause of its fatality 
is often local inflammation. This knowledge, however, is not so 
new as is taught by some modern systematists. Galen (De Affect. 
Intern, c. xli.) taught, that in continual fevers bleeding and cold 
drinks were the powerful remedies. Sydenham declares that the 
ignorance of the inflammations in malignant fevers, has been more 
fatal lo the human race than the invention of gunpowder. Baglivi, 
that malignant fevers often depend on a visceral inflammation, 
and Van Swieten knew the frequency of intestinal ulcerations in 
typhus. 

Among the direct results of pathological anatomy, it is shown 
that disease is seldom confined to one organ, or even one system, 
and thus it has utterly shaken the nosological system of Cullen 
and his predecessors, which, you know, consisted in classifying 
disease by symptoms, which were supposed to point out a certain 
and single disease. For example, the nosologists class phthisis as 
an affection of the lung; but pathological anatomy has shown, that 
in many cases it is the result of a disease invading many organs 
and systems, and that the pulmonary disease is but a link in the 
chain of morbid actions. Pathological anatomy, also, has demon- 
strated the inflammatory nature of a vast number of diseases, and 
has thus given us a key to treatment, to prevention, and to pallia.- 
tion, when the disease is incurable. 

The last grand result of pathological anatomy is the discovery 
that a vast number of affections, supposed to be merely lesions of 
function, are more or less connected also with alteration of struc- 
ture. Thus many of the dyspepsias of the nosologists are proved 
to be examples of gastritis, or of other organic diseases; cases of 
asthma turn out to be chronic inflammation with emphysema; the 
palpitations may depend on organic disease which has sprung from 
a carditis, and so on. I need not now dilate on the vast importance 
of such facts to practical medicine. 

But let us now come to an ill-important inquiry. Is patholo- 
gical anatomy to be considered as the basis of medicine i or is it, 
even when combined with clinical observation, the foundation of 
all medical knowledge 1 This inquiry, you will at once perceive, 
involves the question as to whether Hippocrates and his followers 
have done anything for the science, or whether medicine is wholly 
new, an infant, and consequently a weak and imperfect science. 
Are we to despise the works of the ancients, to be ignorant of them, 
and to allow medicine to be in its infancy? In fact, if we review 
the history of medicine from the Hippocratic era to the absurdities 
of Hahnemann, we find that there have been two orders of men, 
one constituting what we may term the school founders, who made 
a theory, and sought to square facts to meet that theory ; these 
have only brought disgrace on medicine. The other class consists 
of the Hippocratic observers ; that is, of men who sought for facts, 



26 



STOKES'S THEORY AND PRACTICE. 



who collected and pondered on these facts, in other words, who 
were Baconian philosophers. It is the labour of these that has 
really advanced medicine. Asclepiades, who lived in the first 
century of the Christian era, declared that the medicine of Hippo- 
crates was a cold meditation of death. The celebrated Thessalus, 
who lived under Nero, in writing to the emperor, makes use of the 
following words : — 

"I have founded a new sect, which is the only true one. I 
have been forced to this, because none of the physicians who have 
preceded me have discovered anything useful, either for the pre- 
servation of health, or for the cure of diseases, and because Hippo- 
crates himself has put forward many dangerous maxims." 

And what was this new doctrine 1 That nature in each case 
pointed out to the patient what was most fit for him, and that 
hence he should be diligently supplied with everything that he 
fancied. 

We have next Paracelsus. He commenced his course of lectures 
at Basle, in the year 1526, by publicly burning the writings of 
Galen and Avicenna, and assured his auditors that a single hair of 
his head contained more knowledge than Hippocrates and his suc- 
cessors. He taught the cabalistic medicine, the intimate connec- 
tion between the planets and the viscera ; he was a vitalist, but 
embodied his vitalism under the shape of a demon, w T ho resided 
within the system, and which he called Archaeus. Diagnosis was 
to repose on the examinations of the stars, and not on symptoms. 
He invented the doctrine of tartar, which is the cause of all dis- 
eases, of accumulation, obstruction, and concretion ; " and I call it 
tartar." says he, " because it contains the oil, the spirit, and the 
salt, which burn the patient as hell does." 

Hahnemann, the founder of the homoeopathic doctrine, may be 
quoted next as an example of these school founders ; and he, like 
his predecessors, expresses himself with all that arrogance, which 
ijnorance, when it pretends to learning, invariably assumes. Speak- 
ing of the Hippocratic medicine, he says — 

" Since this art only consists in a gross imitation of a danger- 
ous and insufficient process, it must be admitted that the true medi- 
cine was not discovered until by me. It is the infallible oracle of 
the art of curing ; it is the sole mode of really curing disease, be- 
cause it reposes on an eternal and infallible law of nature." 

And what is this mode and doctrine ? We have it in four pro- 
positions, and it is hard to say which of them is most revolting to 
common sense. We are told that it is absurd to seek for the cause 
of symptoms in order to remove them ; that we must cure diseases 
by the exhibition of substances which would otherwise produce 
them ; that the dose is to be inconceivably small ; and that there 
are three original diseases from which spring all the maladies 
which afflict mankind — syphilis, sycosis, and the itch. These are 
the fruitful causes of all diseases, epidemic, sporadic, idiopathic, 
and symptomatic. Like his predecessor in quackery and deceit, 



GENERAL OBSERVATIONS. 



27 



he, too, has his syphilis, sycosis, and itch, the oil, the spirit, and 
the salt, which burn the patient as hell does. Like Paracelsus, 
too, he maintains the curability of diseases, and is a disciple of the 
animal magnetism. 

Let us next see how Broussais announced his doctrine to an 
admiring world. 

" After so many vacillations in its march, medicine at length 
follows the only path which can conduct it to truth — the observa- 
tion of the relations of man, with external modifications and the 
relations of the organs of man, one to the other." This is the 
physiological method, because it cannot be followed without study- 
ing life. 

I am more anxious to draw your attention to this doctrine, as 
Broussais may be considered as the source of the anatomical 
school, which, of late, was so completely the fashion — if I may use 
such a term ; and it is a striking instance of the danger that 
attends the idea of our having made a discovery, to see a man 
like Broussais, than whom few have really added so much to medi- 
cine, falling into the same fault of arrogance and contempt towards 
his predecessors. 

At this moment, the medical world, particularly on the continent, 
is divided into two great sects. One may be called that of the 
pathologico-anatomists, the other the Hippocratists. The first 
declares that diseases are primitively local in all cases ; that the 
symptoms — say in a case of fever — are only the results of sympathe- 
tic irritation from some local disease, which is to be attacked with 
vigour ; that pathological anatomy is to be the foundation of all 
practice; that there is nothing approaching to a specific in medicine; 
and that nature makes little or no attempt to cure. Their favourite 
maxim is that saying of Bichat's — " What is observation, if we are 
ignorant of the seat of disease V* 

This is the sentiment of an anatomist, but not of a physician ; 
and we must regret that it once escaped the author of the " Re- 
searches on Life and Death," a book of such interest and such 
beauty, as to captivate even the non-medical reader, and make the 
very name of Bichat be hallowed in our memory. Many are the 
diseases of which we know not the seat ; yet in which observation 
— Hippocratic observation — is of the greatest utility. 

We know not the seat of fever, let the followers of Broussais say 
what they may to the contrary ; yet is observation of symptoms of 
no avail in fever \ Are the effects of contagion, the history and 
nature of epidemics, the termination by crisis, the results of treat- 
ment, of symptoms as connected with prognosis — is the observation 
of these useless or unnecessary \ Sydenham knew not the seat 
of variola ; yet he declared the true principles of its treatment. 
There are very many diseases on which pathological anatomy 
throws but a negative light — if I may use such a term — particu- 
larly affections of the fluids, and the neuroses. 

So much for the doctrine of the anatomical school. I beg of 



28 



STOKES'S THEORY AND PRACTICE. 



you not to misunderstand me as undervaluing pathological ana- 
tomy;' I only wish to show you its true value. I believe there 
could hardly be adduced a single fact in pathological anatomy 
that has not its distinct bearing on practical medicine* And it is 
true that the diseases whose treatment is best understood are those 
whose pathological nature are best known. Even in fever, the 
actual nature of which has not been revealed, great advantage has 
been derived from anatomical researches ; for all the advance in 
our knowledge of this Protean disease consists in ascertaining the 
number, nature, and seat, of the local inflammations which accom- 
pany or rise in the course, and complicate the disease. 

Let us, lastly, revert to the opinion of the Hippocratists. They 
admit that vast advantage has arisen from pathological anatomy ; 
but they see that its light is limited within certain bounds. They 
believe that great advantage is to be derived from the careful study 
of symptoms, even in cases whose pathological nature is not re- 
vealed by the knife. They believe that there are many diseases 
whose local origin cannot be demonstrated; for instance, fever. 
They deny that pathological anatomy is always to be our guide ; 
but admit a rational empiricism, and the use of remedies which 
may be called specifics ; and, lastly, they hold that nature, in many 
cases, makes an attempt to cure ; and that the physician, in the 
words of Hippocrates, is to be the minister and interpreter of 
nature, rather than her master. 

Let us, then, combine the precepts of the founder of medicine 
with the lights of modern science. Let us take observation, and 
that observation rendered fruitful by study, for our guide ; and let 
the observation equally embrace the phenomena of the living as 
well as the dead. Let us be Hippocratists in the dissecting room 
as well as at the bedside. By comparing the practice of these two 
schools, we get more accurate ideas as to their doctrine. The 
anatomists, holding that all diseases are local, direct their whole 
attention to the discovery of the lesion, and its connection with 
symptoms. This, with their doctrine that almost all diseases are 
inflammatory, leads them to a strict general and local antiphlo- 
gistic treatment. Fever is to them symptomatic, and the supposed 
source is to be vigorously attacked in the commencement. Dia- 
thesis, the nature of the epidemic, and the powers of nature to effect 
a cure, are comparatively neglected. They inhibit purgatives for 
fear of increasing the local inflammation, and lose many patients 
for want of a timely support of the powers of life. 

They deny specificism in disease as well as in medicine, and are 
sorely puzzled to explain the extraordinary powers of bark, and 
mercury, and sulphur, and iodine. They despise the experience 
of the past. 

The true Hippocratist, on the other hand, believing that w r e have 
not yet arrived at the knowledge of the local origin of all diseases, 
and particularly fevers, grounds his practice accordingly. He 
draws his experience from the recorded knowledge of the past, and 



REMARKS ON LOCAL DISEASES. 



29 



his own unbiassed observation. When he recognises a local in- 
flammation, he meets it with judgment, taking into account the 
habits, diathesis, epidemic, constitution, and tendency to crisis. He 
trusts much to nature, and watches her operations, particularly in 
fever. He is not afraid of moderate evacuations ; the phantom of 
a local inflammation does not always haunt him ; and even where 
he recognises its # existence, that does not prevent him from using 
a stimulating and supporting treatment, if the general state of the 
patient requires it. He treats particular diseases by particular 
remedies, the utility of which has been proved by experience — 
such as syphilis, scrofula, intermittent fever, and so on. He uses 
the expectant medicine, which is not inactive treatment, but founded 
on the observations of the powers of nature — " Natura morborum 
medicatrix ;" but he never loses the opportunity of doing good, 
when such presents itself, remembering the first aphorism of his 
great master : — 

" Occasio prssceps." 

I have great hopes for medicine, for I see men's minds turning to 
the true path ; and I trust that all whom I now address will deem 
themselves as labourers in the great work. Think what a noble 
science you profess ! the only one relating to earth-born things, 
which, while it ennobles the mind of man, yet softens and expands 
his heart ; whose source is all science, whose end is good to man. 
Above all things follow truth ; nature can never deceive — see that 
you be her faithful interpreter. The great evil is, that there has 
as yet been adopted no means by which the experience of the past 
can be brought fully to bear on the actual teaching and practice of 
medicine. Too often has the physician to create his own instru- 
ments. But when all the scattered facts of medicine are collected, 
whether they be the observations on the living or the dead body, 
as old as history, or as young as to-day : when these votive tablets 
are hung up in the temple of truth, and their facts verified, com- 
pared, and classified, then, and not till then, will you see medicine 
in all her glory. 



LECTURE II. 

General remarks on local diseases — Fixed rules for the guidance of students — Great 
L importance of diagnosis — Existence of pure fever rare — Doctrine of the Humoralist 
and of the Brownists — Pathology of the digestive system. 

I commence the course by entering at once on the subject of 
particular diseases. I am aware that the common practice is to 
occupy the early part of a course on the theory and practice of 
medicine with preliminary discussions on general pathological 
subjects. To this I have strong objections. Every man who as- 
sumes to himself the office of teacher, no matter what the fact may 
be, should presume that his auditors are ignorant of the subject he 

4 



30 



STOKES'S THEORY AND PRACTICE. 



is about to teach ; if he does not he must be unjust to his class. 
Some of the class must be ignorant of the information he wishes to 
convey, and he should take it for granted that all are so. To 
commence with the consideration of general disease would argue 
that the whole class was acquainted with the subject in all its 
bearings, and capable of understanding its principles without any 
previous illustration. I think this is beginning at» the wrong end. 
My plan is first to teach the facts, and then the general principles 
and conclusions to which these facts lead. It is of the deepest im- 
portance in the study of medicine to be able to form a collection of 
laws or fixed principles. In your professional career, nothing will 
give you so much satisfaction as having in your minds a number 
of established facts and fixed rules to bear on every case which 
comes under your cognisance. We commonly hear of the uncer- 
tainty of medicine and the instability of its practice, it is said to 
have as many phases as the moon, and as many changes as the 
tide ; but, after all I think this expression is more general among 
those who know little than among those who know much. Those 
who have successfully laboured in treasuring up a store of deep 
and extensive knowledge are firmly convinced, that, though some 
cases are involved in doubt and obscurity, the general certainty of 
medicine is at present increased far beyond what it was in former 
times. No man, except one in full and extensive practice, earned 
by industry and capacity, can be aware of the vast improvements 
of modern practical medicine, and of the number of lives which are 
saved by the judicious treatment which the rapidly progressive 
improvement of medical science has introduced. Medicine is much 
more certain now than it was in past times. There are two reasons 
for this, one of which is, that at the present period diagnosis, the 
guide and master-key to sound treatment, is more certain. Here 
gentleman, is a great source of certainty in the practice of medicine. 
You will find, in the course of a few years, that the old saying of 
" doctors differ," will become less frequently applicable, because, as 
the education and acquirements of medical men become more ex- 
tended, diagnosis will be reduced to fixed rules, and difference of 
opinion will be very seldom observed. A vast number of local 
diseases, formerly wrapt in obscurity, are now detected with the 
most unerring certainty, and this certainty of diagnosis must bear 
on fixed principles of treatment and similarity of practice. Another 
vast source of increased certainty is the fact, now extensively 
established, that the element of a great number of diseases is the 
same. This is an important law, because the deduction from it is, 
that the principles of treatment are the same in these cases. The 
principles of treatment in a case of hydrocephalus and in a case of 
vomiting from gastritis may be, and often are, completely identical, 
because, in many cases, both are reducible to a common action. In 
the one case we have to deal with inflammatory action in the 
stomach, in the other we have to treat an inflammation of the 
membranes of the brain. The principle in both cases is to deplete 



REMARKS ON LOCAL DISEASES. 



31 



the suffering organ and to diminish or remove everything that 
keeps up irritation. Pathological anatomy, too, has effected a vast 
deal for medicine by the improvements in diagnosis which it has 
introduced, and by reducing to one class a vast number of affections 
formerly supposed to be unanalogous and distinct. 

Before I commence entering on the consideration of the patho- 
logy and treatment of diseases of the digestive system, it is neces- 
sary that 1 should mention another peculiarity of the mode of 
teaching the theory and practice of medicine adopted in this school. 
The ordinary way of lecturing medicine in the schools is this : the 
teacher begins by going over, at great length, the whole subject of 
fevers, and then proceeds to the consideration of the signs, symp- 
toms, and treatment of local diseases. We reverse this mode 
here ; we begin by teaching the pathology and treatment of local 
diseases, or affections of particular organs, and having studied 
these with care and attention, we then proceed to the consideration 
of fevers. In point of fact, we are thoroughly impressed with the 
truth of this splendid conclusion in medicine, that local diseases 
may be considered, as it were, the alphabet of fevers, and that to 
have a distinct and accurate conception of the whole subject of 
fever, it is essentially necessary that we should be acquainted with 
all kinds of local disease. To commence with a class which the 
teacher presumes, or should presume, to be ignorant of the pheno- 
mena of local diseases, unacquainted with the rules on which their 
diagnosis depends, and unacquainted with the principles which 
should regulate their treatment — to begin with such a class by 
entering at once on the subject of fever, would, in my opinion, be 
extremely wrong. You will read in books and hear teachers speak 
of bilious fevers, of nervous fevers, of catarrhal fevers, of gastric 
fevers, and of simple fevers. These expressions are founded on the 
fact of the complication or noncomplication of fever with local dis- 
ease in various parts of the system. If simple fever was the rule, 
and its complication the exception, then, indeed, there would be 
some reason for pursuing the ordinary track of medical instruc- 
tion, and we might commence by teaching the subject of fever, 
independent of local inflammation. But the truth is, that fever, in 
the simple form, is the exception, and its complication the rule, and 
that to have a correct idea of fever, in the general acceptation of 
the term, we must previously possess an intimate knowledge of the 
affections of particular organs. The progress of medicine" has 
established, by the most unquestionable evidence, that simple fever 
is a matter of extremely rare occurrence, so rare, in fact, that you 
might pass through the practice of a fever hospital for years without 
meeting with a single case which you could say was, through its 
whole course, a case of pure, essential fever. Sooner or later its 
character is changed, and the complication with visceral disease 
comes on ; you may take this with you as a well-proved fact. 
You will have, at some period, a complication with local disease 
in the head, or local disease in the chest, or in the belly, or in the 



32 



STOKES'S THEORY AND PRACTICE. 



circulating system, or perhaps all the great viscera in the body- 
will be simultaneously affected. My experience on this point, after 
having attended the fever wards of the Meath Hospital many years, 
is this, that among all the cases which were admitted under such 
circumstances, there were very few indeed in which I could not say 
that the patient had something more than fever. Many were 
admitted who presented no indication of disease in the head, chest, 
or digestive tube ; all that could be said of them, at the period of 
their admission, was, that they had fever; but my experience of 
them is, that, in a vast majority, there was, during their progress, 
unequivocal evidence of the supervention of visceral disease. I do 
not go as far as the disciples of Broussais have gone, nor do I 
mean to say that all fevers are symptomatic ; all I assert is that, 
at some period most fevers are complicated with local disease. I 
admit that there is a vast number of symptomatic fevers, but I 
believe there are two which are essentially simple, typhus and 
intermittent. The progress of medicine has shown that these may- 
exist in the simple form, and that their complications may be 
secondary ; this I believe to be the fact, but the almost invariable 
liability to complication is a point of the highest importance. We 
scarcely ever see typhus accompanied by symptoms of local dis- 
ease; and, with repect to intermittent, in ninety-nine cases out of a 
hundred, visceral disease of the head, or chest, or belly, may, and 
will, supervene. 

Another great fact bearing on this subject, and which patholo- 
gical anatomy has established beyond the possibility of a doubt, is, 
that in the great majority of cases having a fatal termination, death 
is caused by disease of some particular organ or organs. The old 
notion of the cause of death was, that the patient died of debility 
or exhaustion. In cholera, in tetanus, in hydrophobia, we cannot, 
to be sure, demonstrate any appreciable lesion of structure, and 
we may say, if we like, that the patient died of debility ; but this 
does not hold good in cases of fever, for on dissection you will 
generally find disease sufficient to account for death, even though 
there had been no fever at all. From these circumstances it fol- 
lows that in the management of fevers, the attention of the physi- 
cian must be directed to the local affections, or, at all events, that 
to understand fever well and to treat it successfully, he must be 
acquainted with the nature and treatment of every form of visceral 
disease. It will be sufficient for me to call your attention to this 
fact, that there is not a single acute local disease which may not 
occur during the progress of a fever. This is a broad and general 
proposition. If you look to the nervous system you will find, in 
patients who have died of fever, traces of lesion in almost every 
part of it, inflammation or congestion in the cerebrum, in the cere- 
bellum, and in the spinal cord. If you go to the respiratory system, 
you will see all kinds of shades, and varieties of inflammatory 
action, thickening and ulceration of the bronchial membrane, hepa- 
tisation, congestion, and destruction of the parenchymatous tissue, 



REMARKS ON LOCAL DISEASES. 



S3 



effusions of lymph, serum, or pus, into the pleural cavities. As 
you proceed in your examination yot* will discover new lesions ; 
you may see the whole lung filled with lately formed tubercular 
matter, you will meet with the destructive ravages of phthisis. 
You will find the pulmonary tissue converted into a dark and fetid 
mass by gangrene. You may see carditis, hypertrophy, inflamma- 
tion of the external or internal coverings of the heart, inflamma- 
tion of the lining membrane of the arteries, phlebitis, (a common 
occurrence in typhus fever,) and passing on to the lymphatic sys- 
tem, you will often find evident traces of inflammation in its glands 
and vessels, an occurrence which I shall be able to demonstrate to 
you when treating on the subject of gastric fever. If we go to the 
digestive system we find that disease has here taken a wider 
range ; congestions and ulcerations of the stomach and intestines, 
morbid states of the liver, congestion and inflammation of the spleen 
or kidneys, evidence the fatal extent of local inflammation. I 
think I might safely challenge any one to point out any one single 
organ which may not become diseased during the progress of a 
typhus fever. I do not wish you to suppose that typhus is a symp- 
tomatic affection. I think we may define it, in general terms, as a 
diseased state of the whole system, in which various local diseases 
arise, modify the character of the original complaint, give it an addi- 
tional intensity, and are generally the cause of death. Go round 
the wards of an hospital during the prevalence of an epidemic fever, 
examine every patient in succession, and bring this principle to 
the test. You will see one labouring under the morbid excitement 
of high delirium ; his face injected, his eyes sparkling, his carotids 
throbbing with intensity. Come next day, and you will find him 
in a state of profound coma, perfectly insensible to everything 
around him : — two or three days afterwards he is dead. You follow 
his body to the dissecting room, and open his brain ; unequivocal 
marks of excessive congestion, inflammation of the substance of the 
brain, or of its membranes, sufficiently indicate the cause of the 
fatal termination. Here is a case of inflammation of the brain. 
You find another with cold skin, his face of a dirty hue, faintly 
tinged With red, his breathing quick and hurried, and the spitting- 
vessel by his bedside filled with adhesive mucus tinged with blood ; 
you percuss his chest and find dulness over the whole surface of 
one lung ; you apply the stethoscope and discover intense bron- 
chitis, hepatisation, or suppurative pneumonia. Farther on you 
see another in a state of deep prostration, with a sunken counte- 
nance, constant hiccup, and low delirium. Take down his bed- 
clothes, and you find his belly swelled, tympanitic, and tender on 
pressure ; then his tongue, lips, and gums, are parched and encrusted 
with dusky sordes ; his thirst is insatiable; he vomits, and has an 
emaciating diarrhoea. After death you find traces of an extensive 
and fatal gastro-enteritis ; in others you will find exemplified the 
very climax of inflammation, and all the three great cavities are 
simultaneously affected. 

4* 



34 



STOKES'S THEORY AND PRACTICE. 



But these, you will say, are cases in which the complications 
are evident, and where an ordinary knowledge of the phenomena 
of local disease will be quite a sufficient guide. Well, here is 
another case. You will meet with instances of fever without any 
apparent local symptoms, where the patient lies in what you would 
consider a quiet state, and free from danger : nothing seems to be 
the matter with him, except that he is very weak ; he perhaps does 
not sleep at night, and his tongue is a little foul ; he complains, in 
feet, of nothing but weakness and some thirst, and you think his 
fever is going on very well. Some morning or other, on coming 
to the hospital, you are astonished to see the change which has 
been wrought in him since the day before ; his countenance is 
altered, his pulse can hardly be felt, and life is fast ebbing away. 
You ask the nurse about him, and she tells you that, during the 
night he suddenly complained of violent pain in his belly. On 
examining him, you find distinct evidence of intense peritonitis, 
and, after death, dissection reveals the existence of a perforating 
ulcer of the intestines, of which there was apparently no sign 
during life, except fever and the unexpected occurrence of peri- 
tonitis. The frequency of the complication of local disease with 
fever, its insidious latency, and the fact, that death, in the majority 
of fever cases, is caused by visceral inflammations, all clearly point 
out the necessity of being intimately acquainted with every modi- 
fication of local disease before you proceed to the study of fevers. 

I commence with the digestive system. I am anxious to do this 
for several reasons, but for none more than this — that to the im- 
provements made in the pathology of the digestive system we owe 
much of the rapid advancement of modern practical medicine. 
Before our time the pathology of the digestive system was very 
little known, and if not quite a terra incognita in medicine, there 
existed respecting it a great deal of misconception. The schools 
were deeply tinctured with the doctrines of the Humoralists and 
the Brownists ; and this had the effect of giving rise to irrational 
theories and false notions of the true state of the system in disease. 
The humoral pathologists, who sought for disease in an alteration 
of the fluids alone, neglected the study of visceral lesions ; and 
when they turned their attention to the digestive system, they only 
considered it, its secretions, and not its actual condition or the 
state of its sympathies. The liver, with them, was an organ of the 
highest importance, and the secretion of bile claimed a vast share 
of their attention. To it they gave a paramount influence, and to 
an alteration in its quantity and quality they attributed most of the 
changes which occur, not only in the digestive tube, but also in 
the whole system ; and hence the great object of their practice was 
to attempt to restore its healthy condition, convinced that if this 
were once accomplished everything would go on favourably. 
From this, too, arose the purgative plan of treatment in various 
forms of intestinal disease, a plan too often rashly pursued, even 
where there was unequivocal proof of inflammation in the diges- 



REMARKS ON LOCAL DISEASES. 



35 



tive tube.* Their sole purpose was to evacuate sordes, to produce 
a flow of healthy bile, and to eliminate depraved secretions ; and 
they did this without possessing any knowledge of local inflamma- 
tion, or of the effects of disease of the digestive system on other 
organs. The followers of Brown, on the other hand, only admitted 
disease of the digestive system in a state of intense, manifest vio- 
lence, as, for instance, ileus or violent enteritis ; but in the great 
majority of cases, they did not recognise intestinal inflammations, 
because their prominent symptom was prostration, or, to use their 
own terms, an asthenic condition of the whole system. They saw 
nothing but prostration; they prescribed for nothing but debility; 
they gave wine instead of iced water ; ordered bark instead of local 
depletion. They exasperated the disease by stimulants ; and then, 
thinking they had not gone far enough, they heightened the stimu- 
lant and doubled the debility. 

Another cause of the low state of pathology in former times was 
the general neglect of dissection. The fact is, that in fever there 
were no post mortem examinations made, until very lately. Mor- 
gagni, who did so much for pathological anatomy on almost every 
other subject, did little for fever, because be was afraid to dissect 
the bodies of persons who had died of a contagious disease. This 
was the idea which prevailed among the older pathologists; and 
hence this source of knowledge was avoided, and for many succes- 
sive centuries the state of the viscera in fever was a matter of specu- 
lation, doubt, and uncertainty. Even at the present day it is only 
done by the ardent pathologist, who cares not about filth and stench, 
and who had rather encounter the miasm of contagion than remain 
in the mists of error. Nothing is more common, I regret to say, 
even at the present time, than this :— A person says he has dis- 
sected cases of fever, and when asked whether he had examined 
the intestinal canal, he says that the intestines appeared healthy, 
but he did not make any particular inspection of them ; he only 
opened the belly, and, finding no trace of inflammation in the peri- 
toneum, he went no farther. Now nothing can be more useless 
than such an examination. If we compare the information afforded 
by an inspection of the serous membranes of the three great cavities, 
we shall find that the least is given by an examination of that of 
the abdomen. Disease of the substance of the brain is rare with- 
out affections of its investing membrane, disease of the substance of 
the lung is exceedingly rare without the occurrence of disease of 
the pleura, but you may have most extensive and fatal disease of 
the intestinal canal, without the slightest lesion of the peritoneum. 
In this point, therefore, it differs from the pleura, and from the 
arachnoid membrane. The fact of the rarity of disease of the peri- 
toneum in cases of disease affecting the parts beneath, was noticed 
by Dr. Graves and myself, in our report of the Meath Hospital, and 

* [Our medical brethren of the south and west, will see, if not reproof, at least 
a salutary hint, in these remarks of the lecturer. — B.] 



36 



STOKES'S THEORY AND PRACTICE. 



also by Mr. Annesley, in his account of the diseases of India. You 
will see cases of hepatic abscess, which present a distinct tumour 
externally, and where you can detect a perceptible fluctuation ; 
and yet, if you examine these cases, after death, you may not find 
any adhesions of the peritoneum, even in the situation of the ab- 
scess. You will find the mucous and muscular coats of the colon 
extensively destroyed, you will see the stomach all bat perforated, 
you will meet with cases where the whole ileum is one extensive 
sheet of ulcerations, with no disease in the adjacent peritoneum. 

In entering on the consideration of diseases of the digestive 
system, we shall begin first with the mucous expansion of the sto- 
mach and intestines, and then proceed to the affections of the solid 
viscera connected with them. The mucous surface of the stomach 
and intestines is of enormous extent and extraordinary sensibility, 
possessed of innumerable and powerful sympathies ; its influence 
is felt by almost every organ in the body, formed for receiving and 
elaborating everything destined for nutrition : its conditions, both 
in health and disease, are entitled to the deepest and most attentive 
consideration. To facilitate the study of its affections, and for the 
sake of some practical arrangement, we shall divide its diseases 
into five classes, beginning with the oesophagus, or that portion of 
the digestive tube which is above the diaphragm, and then pro- 
ceeding to the stomach, duodenum, ileum, colon, and rectum. But, 
in order to give you a clear idea of diseases of the intestinal canal, 
I shall commence with diseases of the stomach ; because, if you 
consider the whole range of animal life, you will find that its func- 
tions are the most important, the stomach constituting, as it were, 
the source and fountain of life, which is nutrition, and giving by 
its existence a character to all the upper classes of animals. No 
organ possesses such remarkable sympathies as the stomach, whe- 
ther we look upon them as sympathies of organic or of animal life, 
none possesses such remarkable power and influence in modifying 
the condition of every part of the system. ^ But, putting aside phy- 
siological reasons, let us come to practical matters. The success of 
almost every form of medical treatment, all the advantages to be 
derived from the administration of internal medicine, depend upon 
the stomach ; in fact, in whatever point of view we consider it, we 
must look upon a knowledge of the state of the stomach as the great 
key to sound and successful practice. 

It is a most useful reflection to consider the extraordinary fre- 
quency of disease in some portion of the digestive tube. It is now 
admitted by every person possessed of experience in the causes of 
mortality, that more human beings die with acute or chronic dis- 
eases of the digestive tube than with diseases of any other part of 
the system. This has been established by numerous investigations, 
and is admitted by the best pathologists ; and, indeed, I think it 
can be easily accounted for, when we call to mind how many per- 
sons die of some form of fever or other, when we look to the ravages 
of remittent and yellow fever, to the hundreds of thousands who, 



REMARKS ON LOCAL DISEASES. 



37 



annually perish by the various classes of fevers. Now, in almost 
every one of these cases, disease of the digestive system forms one 
of the most prominent pathological characters. Recollect, besides, 
all that die of dysentery, whether sporadic or simple, and here is 
inflammation of the colon ; see, too, how many die with diarrhoea — 
here, too, there is intestinal disease; remember how many die of the 
malignant intermittent of the West Indies, in which unequivocal 
proofs of disease of the stomach and intestines have been found. 
Observe what a close connection there is between tabes mesente- 
rica, and inflammation of the mucous membrane and surface of the 
intestines ; think what a vast number of persons fall victims to the 
harassing effects of constipation and dyspepsia ; and recollect that 
there is a host of diseases in which the train of morbid phenomena 
commences in the digestive system, and then exhibits itself by 
functional alteration or organic disease of other parts. 

We recognise the presence of disease in the digestive tube, first, 
by the local phenomena and the lesion of the digestive function, 
and next by the sympathetic relations of other parts, by the sym- 
pathies of the respiratory system, of the circulation of the skin, and 
of the nervous system. I shall enumerate the local phenomena 
and functional lesions : vomiting, anorexia, thirst, jaundice, pain, 
tenderness on pressure, tympanitis, changes in the character and 
quality of the discharges, constipation. Here are a set of functional 
lesions and local phenomena ; let us now consider the sympathetic 
relations; these are fever, heat of skin, suppression of the cutane- 
ous secretion, suppression of the secretion of urine, morbid states 
of the tongue and pulse, pains in the chest and cough, hurried 
breathing, and palpitations of the heart. In the next place, we may 
have prostration of strength, delirium, coma, convulsions, tetanic 
spasms, and other symptoms of functional disease of the brain; 
these are all sympathies of relation. Now, in the first place, I 
have to remark, that there is a great deal of variety in the combi- 
nation of these symptoms. On what does this depend ? on a variety 
of circumstances ; sometimes on the intensity or extent of the in- 
flammation: sometimes on the situation of the disease; sometimes 
on the complication of the affection ; sometimes on the various 
modes and degrees of susceptibility of the individual. All these 
causes tend to produce a great variety in the disease, and an exten- 
sive modification of the sympathetic relations. For instance, in 
some cases inflammation of the stomach and intestines is so slight 
that the patient is not prevented from going about and pursuing 
his ordinary avocations ; in others, on the contrary, the patients 
are struck down at once by the violence of the disease, and are 
carried off by the fever which accompanies it before the inflamma- 
tion is completely developed. It varies also according to situation ; 
there is a difference between gastritis and dysentery : in the former 
we have an inactive state of the great intestine, and consequent 
constipation ; in the latter, the colon is thrown into violent action, 
and there are frequent dejections. Disease of the duodenum is 



38 



STOKES'S THEORY AND PRACTICE. 



attended with a very remarkable peculiarity, being very frequently 
complicated with jaundice; here is a modification produced by 
situation. Again inflammation of the ileum is attended with a 
very curious peculiarity, namely, the absence of pain. The patient 
states, that he feels unwell, he has obscure symptoms of intestinal 
disease, but it is neither dysentery nor gastritis ; you investigate 
it with care and find that the ileum is in a state of inflammation. 
Yet the patient does not complain of any pain, and this is another 
peculiarity depending on situation.* 

But in considering the differences which depend upon intensity, 
extent, and situation of disease of the intestinal canal, we must not 
omit those which depend upon tissue. If disease be confined to 
the mucous membrane of the intestines alone, we may have an 
extremely diffused and extensive inflammation, sufficient to destroy 
life, without any pain being complained of by the patient ; it is a 
painless though fatal disease. Recollect this, extensive and fatal 
inflammation without pain. In former times the ideas of pain and 
inflammation were inseparable. Thanks to the light which patho- 
logy has shed upon modern medical science we are now acquainted 
with this seeming anomaly, and can conceive the existence of ex- 
tensive disease of mucous surfaces unaccompanied by pain. But 
let the inflammation seize on the muscular tissue, the character of 
the disease is instantly changed, and the pain is dreadful. Here 
is a case in which difference of tissue is to be taken into consider- 
ation.! 

The phenomena and sympathetic relations of intestinal disease 
may vary also according to its complication, and here we come to 
investigate one of the most beautiful laws of the human economy, 
namely, that the more complicated a disease is the more latent will 
be any local lesion. This is a point that should never be forgotten. 
For instance, enteritis by itself is much more easily recognised 
than when complicated with pneumonia, or with irritation of the 
brain, and gastritis is but too often completely masked by being 
combined with irritation of the bronchial mucous membrane. 
Lastly, we have the varieties which depend on different degrees of 
susceptibility. In one person we may have only slight cerebral 
irritation, in another high excitement, in a third delirium and ex- 
traordinary convulsions. The variety, then, in the modifications 
of diseases, and the combination of sympathies, is very great, 

* [The physiological explanation consists in the nervous supply to the ileum, 
coming from the sympathetic ; a fact of importance, which should be borne in mind 
in making our prognosis of typhous fever. The absence of pain might induce 
belief that there was no organic lesion. — B.] 

f [The position is, perhaps, rather too broadly laid down in the text. The 
sensations of the patient will depend very much on the portion of intestine affected ; 
whether duodenum, for example, or jejunum, and whether even the upper or the 
lower part of the ileum. The first and last portions of the intestinal canal re- 
ceive branches of the cerebro-spinal nerves, — the middle is supplied almost entirely 
by the sympathetic. — B.] 



DISEASES OF THE DIGESTIVE SYSTEM. 



39 



and is referable to the extent and the intensity of the inflammation, 
difference of situation, complication of disease, difference of tissue, 
and different degrees of susceptibility. I shall give examples of 
these at my next lecture, and then proceed to the pathology and 
treatment of gastritis. 



LECTURE III. 

Pathology and treatment of diseases of the digestive system — Different forms of gastri- 
tis — Pathology of this disease imperfectly understood by the ancients — Gastritis and 
enteritis not always found in connection — Phenomena characterizing acute gastritis 
— Symptoms and sympathetic relations — Diagnosis — Gastritis simulating other dis- 
eases. 

The consideration of the pathology and treatment of diseases of 
the digestive system shall occupy our attention to-day, I shall 
commence with the study of gastritis, and to this subject I would 
entreat your undivided attention ; not that I have anything very 
new to communicate, but because I believe that many of the state- 
ments, which are connected with this disease, will be found to rest 
on the basis of fact and truth, many of them will be found useful 
in your future practice, and this subject, I fear, is not sufficiently 
considered in the schools of medicine of this and the sister countries. 

The older authors describe gastritis as occurring under two dif- 
ferent forms, one of which they termed phlegmonous, and the other 
erysipelatous. The advanced students know the meaning of these 
terms, and that they are admitted as significant of different modifi- 
cations of the inflammatory process, but to those who are not ad- 
vanced I shall state that it is very difficult to give an accurate idea 
of these terms, so far as they are applicable to cases of internal 
disease. But we may attempt a general definition by saying, that 
phlegmonous inflammation occurs in a good constitution, and under 
favourable circumstances, that it is an inflammation of a bold and 
distinct character, requiring and admitting of depletion, and, like 
that on the external parts, terminating in healthy suppuration, or 
adhesion. Erysipelatous inflammation is (described to be) a disease 
of a different kind, occurring in bad and debilitated constitutions, 
and under such circumstances that the same treatment, employed 
in the phlegmonous form, is more or less inadmissible ; and when 
stimulants are necessary, if not in the commencement, at least at a 
very early period of the disease. It is quite impossible to found any 
system of pathology on this division into phlegmonous and erysipe- 
latous ; we are, however, sometimes obliged to make us of it for 
want of a better. The terms themselves are highly calculated to 
mislead. Healthy inflammation, which is all but a contradiction in 
terms, may occur in a debilitated constitution, and erysipelaotus in 
a strong one. The latter of these, too, is particularly erroneous, 
as we now know that erysipelas may occur under opposite cir- 
cumstances. In the one case, requiring the lancet and leeches, and 



40 



STOKES'S THEORY AND PRACTICE. 



purgation ; in the other, demanding a stimulant and tonic treatment. 
In speaking of gastritis I do not intend to adopt this division, be- 
cause it would be likely to embarrass you, and, in truth, it is un- 
necessary, as there is no difference in the (principles of) treatment, 
whatever may be the form of this inflammation. The proper way 
to consider gastritis is to look upon it as a disease, presenting, on 
the one hand, symptoms of extreme violence and urgent danger ; 
on the other, feebly shadowed out by the phenomena of ordinary 
and slight indigestion. Between these there are many shades and 
numberless gradations. The phlegmonous gastritis of the old 
authors implied a violent and extensive inflammation, in which all 
the coats of the stomach were implicated ; but, in treating of the 
subject of gastritis in these lectures, I shall only allude to inflam- 
mation of the mucous membrane and glandular apparatus of the 
stomach. The other tissues are sometimes engaged, but the 
mucous membrane, constituting the most important of these tissues, 
and forming an exquisitely delicate vasculo-nervous expansion, is, 
in the great majority of cases, the principal seat of inflammation, 
and to this I would direct your particular attention. 

The true pathology of gastritis was but very imperfectly under- 
stood by the ancients. They knew enteritis and gastritis as intense 
inflammations of the coats of the stomach and intestinal canal, 
accompanied by violent pain and fever, but they had no conception 
of their various shades and modifications. For a knowledge of the 
true nature of gastritis, and of its numerous varieties, we are in- 
debted to modern pathology, and it is the boast of pathological 
anatomy to say, that in this instance its labours have shed a broad 
and vivid light on a class of diseases previously involved in deep 
obscurity. 

It has been stated, that it is impossible to separate the symptoms 
of gastritis from those which characterize enteritis, and the reason 
given for this is, that the two affections frequently co-exist. This 
is a proposition of vast importance. It is said, that in cases where 
you have gastritis, the chances are that there is more or less of 
enteritis ; but according to this doctrine, if a man has gastritis the 
probability is that he has inflammation of some other portion of the 
intestinal canal. Broussais, in the 138th proposition, makes the 
following observations : — " Inflammation of the stomach, or, as it is 
called, gastritis, is never found except in conjunction with disease 
of the small intestine. It is better, therefore, to give it the name of 
gastro-enteritis ; and even in those cases, in which we have enteri- 
tis, we have gastritis as the irritative." Now if this proposition is 
true, it is one of very great importance, and entitled to a large 
share of our attention, in studying the phenomena and treatment 
of inflammation affecting the digestive tube. Pathology, however, 
has proved that these inflammations are not always found in con- 
nection. Andral gives many cases, in which disease existed sepa- 
rately in one or other portion of the intestinal canal ; when it was 
found in the stomach and not in the duodenum or ileum, and when 



DISEASES OF THE DIGESTIVE SYSTEM. 



41 



it was found in the ileum, but not in the duodenum or stomach. I 
myself have seen many examples of gastritis without disease of any 
other part of the digestive tube, and disease of various parts of the 
digestive tube without the co-existence of gastric inflammation. 
But I believe the proposition is generally true, particularly in 
cases of fever, in which you have secondary inflammation of the 
digestive tube during the course of the disease. When inflamma- 
tion attacks the intestinal mucous surface during the progress of 
a fever, you will, in most cases, have these two diseases com- 
bined ; the patient generally presenting symptoms of gastritis, and, 
at the same time, symptoms of enteritis affecting the lower third of 
the ileum.* 

Let us now proceed to investigate the phenomena which cha- 
racterize acute gastritis. Here I must remark, that, as an idiopathic 
disease, acute gastritis is extremely rare. This is a very curious 
circumstance. When we compare the stomach with other viscera, 
we shall find that one of the most remarkable differences between 
it and other organs is, that it is much less liable to be attacked by 
violent inflammation, as an idiopathic affection. This is an inte- 
resting fact. So rare, indeed, is the violent form of gastritis, that 
our knowledge" of the symptoms which indicate intense gastric 
inflammation is principally drawn from the study of cases of acute 
gastritis caused by swallowing corrosive poisons. We very seldom 
meet with an inflammation of the stomach, presenting those decided 
characters so frequently witnessed in similar affections of other 
organs. We may attempt to explain this fact, by considering what 
the functions of the stomach are, and by recollecting that it is the 
organ of the body, wmose functions require that it should be most 
frequently in a state of great vascular excitement. Every one is 
aware that the vascularity of the stomach is amazingly increased 
during the act of digestion ; but it is to be remembered that this is 
a physiological and not a pathological condition. If the stomach 
were as liable to inflammation as other organs, it could no longer 
carry on its functions with safety; every meal would prove a 
stimulus sufficient to excite inflammation — every digestion would 
be followed by gastritis. Nature has provided against such 
accidents. 

Let us take a brief review of the symptoms of acute gastritis : — 
intolerable thirst, desire for cold and acidulated drinks, constant 
nausea and vomiting, pain and burning sensation of heat about the 
stomach, and fever — these are the symptoms of a violent gastritis. 
It has been stated, that in gastritis the fever is at first inflammatory 
and afterwards typhoid. If authors mean by this, that the patient 
rapidly falls into a low typhoid state, the observation is true. 
There is no form of inflammation, except that which accompanies 
severe peritonitis, in which the typhoid state comes on so rapidly. 

*■ [A state of things this very common in our remittent fevers, as well bilious 
as those which soon assume a typhoid character. — B.] 

5 



42 



STOKES'S THEORY AND PRACTICE. 



Inflammations of the digestive tube differ, in general, from similar 
affections of other organs, chiefly in this — prostration rapidly super- 
sedes excitement. A patient labouring under inflammation of the 
brain will exhibit, for a long time, decided symptoms of high ex- 
citement, and of what has been termed the phlogistic diathesis ; 
acute pneumonia and inflammatory affections of other parts will 
go on for days, without prostration, and require the use of the 
lancet ; but gastritis is a disease in which the inflammatory symp- 
toms, as they are called, last but for a very short time. In violent 
cases the irritation of the stomach is excessive, and everything is 
rejected. I have seen cold water thrown up almost immediately ; 
I have seen effervescing draughts rejected the moment they were 
swallowed, and make the patient evidently worse. The epigastric 
region and the left hypochondrium are exquisitely tender on pres- 
sure, and the tenderness differs from that of peritonitis in this, that 
it is almost always localized. The patient screams with agony 
when you touch the epigastrium, but will bear pressure freely on 
the lower part of the abdomen. 

Now, with respect to the sympathetic relations of gastritis, I have 
to remark, that they are very numerous. First, as to respiration- 
it is extremely quick and hurried ; the heart, also, is violently ex- 
cited ; and hence gastritis has sometimes been mistaken for pneu- 
monia and pericarditis. Sometimes we have bronchitic cough ; 
the patient is restless, gets no sleep, and is extremely uneasy; his 
skin is hot, his bowels confined, his pulse rapid and smalL In the j 
second stage, he is beginning to sink, his features become con- 
tracted, his skin cold and pale, his extremities sunk below the 
natural temperature ; he now bears pressure ; the vomiting is j 
changed for regurgitation of everything he swallows; low delirium 
supervenes, and he dies. , 

It is of the greatest importance to attend to the sympathetic rela- | 
tions of gastritis, for this reason, that in many cases the local 
symptoms are all but wanting, and the disease is only to be known ! 
by its sympathetic relations. Before I enter on this subject I shall 1 
make one or two remarks on some symptoms which have not been ! 
attended to by many practitioners. One of these is an incapability 
of swallowing, sometimes so great that all ingesta, whether fluid 
or solid, are rejected. This will sometimes arise from spasmodic 
stricture of the oesophagus or cardiac orifice of the stomach ; and, 
as there has been no other cause revealed, by dissection, in several 
cases in which this symptom was present, we must admit this as 
one of the causes of the dysphagia, which, on some occasions, 
attends gastritis. This symptom is most commonly accompanied 
by tightness and oppression about the prsecordia. The patient, 
feeling a load or weight, as he expresses it, in this situation, thinks 
it would be relieved by vomiting, and begs his medical attendant to j 
give him an emetic, which is sometimes administered, and pro- 
duces very bad effects. There is only one case in which an emetic 
can be given in gastritis, and that is, where indigestible or irri* 



DISEASES OF THE DIGESTIVE SYSTEM. 



43 



tating substances in the stomach give rise to irritation, and when 
we cannot expect a favourable termination until we effect their 
removal. 

There is another most disagreeable and distressing symptom, 
generally occurring in cases in which there is inflammation about 
! the cardiac orifice of the stomach — I mean hiccup. Hiccup is a 
most harassing symptom ; it does not allow the patient a moment's 
rest; in his brief and uneasy slumbers he is conscious of it, and is 
constantly awakened by it. Now, this is also one of the results of 
gastritis, with inflammation about the cardiac orifice. I say this, 
because I have seen it in many cases, in which there was distinct 
evidence of inflammation about the cardiac orifice of the stomach ; 
and, in three instances, I have verified it by dissection. I do not 
mean to say that every case of hiccup is indicative of disease of the 
cardiac orifice, but I believe it is a very frequent accompaniment. 
The case of a celebrated professor of languages was a remarkable 
example. A short time previous to his death, he came from Liver- 
pool in one of the steam packets. He was always subject to sea 
sickness ; but on this occasion he was extremely ill, and vomited 
during the entire passage or sea voyage. He complained of his 
stomach for some time, and then got hiccup, which resisted every 
kind of treatment, and continued without any abatement up to the 
time of his death. On opening the stomach, this organ was found 
in a state of intense inflammation, particularly about the cardiac 
orifice. You can see the stomach (of which a very good prepara^ 
tion has been made by Dr. Houston) in the museum of the College 
of Surgeons. There was another very remarkable case in the 
Meath Hospital. A patient was admitted who had laboured under 
acute pneumonia, for which he was treated with tartar emetic, and 
the symptoms rapidly declined, but vomiting and hiccup came on, 
and the latter symptom continued until death. We opened the 
body eighteen hours after his demise, and found the lung quite 
healthy ; but the stomach, and the cardiac orifice in particular 
were, as in the case I have just mentioned, in a state of intens* 
inflammation. When hiccup is the result of inflammation of the 
cardiac orifice, you will also frequently observe that the patient 
complains of pain in the lower part of the chest, along the course 
of the diaphragm. These are some of the relations of gastritis, 
their connection with which is proved by their being relieved by 
draughts of cold water, leeching, and every other means calculated 
to remove inflammation of the stomach. 

We come now to consider the state of the tongue. A vast deal 
of error and misconception prevails among British practitioners on 
this subject. Nothing is more common, than from the condition of 
the tongue to form an opinion as to the state of the alimentary canal. 
For instance, whether it is in a state of inflammation, whether there are 
sordes present or not, and whether it requires this or that medicine. All 
this is behind the actual state of medicine, and it is melancholy to think 
what a vast quantity of mischief is done by those practitioners who 



44 



STOKES'S THEORY AND PRACTICE. 



take the tongue as the index of an inflammatory or non-inflamma- 
tory condition of the intestinal canal. The schools of Abernethy 
and Broussais are wrong in stating that the tongue will point out 
the state of the digestive tube. The connection between the state 
of the tongue and that of the stomach, has been lately made the 
subject of extensive clinical investigation by M. Andral ; listen to 
his sentiments on this point. From the experience of a vast number 
of cases, he declares " that there is no constant relation between the 
state of the tongue and that of the stomach." In the next place he 
states," that there is no modification of the one corresponding with 
any special modification of the other." " Thirdly, the stomach may 
be found in a certain state after death, with various conditions of 
the tongue during life." " Fourthly, we may have a diseased sto- 
mach with a healthful condition of the tongue, and diseased ap- 
pearance of the tongue with a healthful state of the stomach." 
These are facts of the greatest importance. Let us now refer to 
Louis. In giving an account of the gastritis which accompanies 
fever, he states that in many of the worst cases the appearance of 
the tongue was natural, in fact, that there was not the slightest re- 
lation between the tongue and the stomach. It is fair, however, to 
observe here, that both these pathologists drew their information 
only from cases of gastritis, occurring in fever. But it has also 
been frequently observed, that even in idiopathic cases there is a 
want of correspondence between the condition of the tongue and 
stomach, and we have seen several instances of this in the Meath 
Hospital. I believe we should be wrong in taking the tongue alone 
as our guide in the treatment of intestinal derangement, whether ex- 
isting in the stomach or any other portion of the tube, and this I 
state as the conclusion which I have drawn from my own experience, 
in gastric and enteric inflammation. Yet how many will you see 
taking the tongue as the unerring index of various conditions of the 
digestive tube? hundreds and thousands. It is unquestionably true, 
that in certain cases of gastritis, particular morbid appearances, as 
redness, dryness, pointing, and a tremulous state of the tongue, are 
observed, but what I wish to impress on you is, that it is necessary that 
these phenomena should coincide with other symptoms. I do not wish 
you to believe, that the inspection of the tongue, or the knowledge 
derived from its appearance, is useless, particularly in cases of fever: 
the state of the tongue is never to be overlooked, but you should un- 
derstand on what principle it is to be examined. You should ex- 
amine the tongue not so much as a guide to the knowledge of local 
disease, but as an index of the condition of the general system. 
For instance, if, during the course of a fever, the appearance of 
this organ changes and becomes more favourable, it is a sign that 
the whole disease has taken a favourable turn, and vice versa. 
This is the proper way to look at the tongue in fever, not as re- 
flecting any particular state of the intestinal canal, but as being in- 
dicative of some modification of the whole economy.* 

* [I know well a person, who, for the last twenty-five years, has never had an 
entirely clean tongue ; and who for years used to awake every morning with his 



DISEASES OF THE DIGESTIVE SYSTEM. 



45 



Let us now consider the sympathetic relations of the nervous 
and respiratory systems in gastritis. This is a very curious and 
interesting point in the study of gastric disease. I may mention here, 
that these relations are subject to considerable variety, and differ 
according to the peculiar predisposition of the individual. If a 
person of nervous habits gets gastritis, he will be very liable to have 
sympathetic affections of some part of the nervous system ; but if 
he is a person with unsound lungs, the irritation will be transferred 
to the respiratory apparatus. Can we define these irritations ? I 
believe the best definition we can give of them is, that they are 
affections of some organ, which are the result of sympathy ; and 
that they are at first functional, but afterwards become organic. 
A person of nervous habit, labouring under gastritis, will frequent- 
ly have his head sympathetically affected ; he will complain of head- 
ache, more or less intense ; toss about and get no sleep ; still he has 
no actual disease of the brain. But let the cerebral irritation go on, 
let the pain and uneasiness and watchfulness continue, and he will 
finally get arachnitis. So, too, with respect to the lung ; the patient 
has hurried breathing and cough, without any of the stethoscopic 
signs of pulmonary disease ; but if these symptoms continue for any 
length of time, or if the irritation be severe, he will get pneumonia 
or bronchitis. Observe the importance of this law with reference 
to treatment, because it shows you that you cannot always expect 
to remove sympathetic affections by attacking the original source 
of disease ; for if functional derangement, produced by sympathetic 
irritation, has gone so far as to become organic, you must direct 
your attention to parts which have been secondarily engaged, as 
well as to those which are primarily affected. Every one is aware 
of the effects of particular states of the stomach on the brain, and 
of the influence which the brain exercises over the stomach. Most 

tongue dry, furred, and yellow, or often brown, and sometimes giving outa little blood 
mixed with the first saliva. In fact, the tongue of this individual often resembled 
that of a patient in the advanced stage of typhoid fever; and yet he has been 
seldom laid up by sickness. His digestion was regular, but slow and laborious ; 
and was particularly troublesome in the colon, in its being attended with flatulence, 
and alternate diarrhoea and constipation. His renal secretion was habitually 
disordered by the presence of uric acid. He was a moderate eater, and abstinent 
generally from all kinds of intoxicating liquors. He found that the appearance 
of his tongue and the dryness of his mouth, together with epigastric heat and 
tenderness, was increased much more evidently by late hours of even quiet study, 
than by indulgence in suppers, or the occasional excesses of the table. Of late 
years, his brain and nervous system have been less continually excited, and^ he 
now awakes in the morning with a moister and less morbid tongue; although his 
dyspepsic symptoms are nearly as before. But whilst thus adducing evidence in 
support of the opinion advanced in the text, I ought to add, that any unusual 
article of food, salted or smoked meat, pastry, or an apple at dinner, will cause 
disturbed sleep and a drier tongue the next morning in this individual. A cir- 
cumstance worthy of notice, in his case, is, that, when he happened to awake in 
the night, or at two or three or four o'clock in the morning, his tongue was moist, 
and his mouth without any feeling of dryness or discomfort : but after the last 
sleep, and at the common hour of rising, the tongue and mouth would be dry and 
parched, and otherwise changed, as above described. — B.] 



4G 



STOKES'S THEORY AND PRACTICE. 



individuals know, that by grief or strong mental emotion the appetite 
is completely removed ; and that after a surfeit, or from taking bad 
and indigestible food, a person will get sick headache. If this hap- 
pens every day under ordinary circumstances, and where the ori- 
ginal affection is so slight that it does not interfere with the usual 
avocations of the patient, you can readily conceive how intense the 
sympathetic irritations may be in a case of violent gastritis. The 
headache is frequently intense, the patient is extremely restless, 
there is considerable intolerance of light, delirium, tetanic spasms, 
and other symptoms characteristic of inflammation of the brain. 
There are numerous cases on record in which these symptoms were 
particularly noticed, and it was supposed that the brain was in a 
state of inflammation, but on dissection there was no disease found 
except in the mucous membrane of the stomach. There are many 
cases, too, in which medical men, not aware of the extent of these 
relations, looked upon the disease as a pure cerebral affection, and 
directed their whole attention to the brain. They certainly suc- 
ceeded in modifying the apparent disease, but as they took no steps 
to remove its cause, the patients generally sunk from an unsuspected 
gastritis. There is one important law with respect to inflammation 
of the stomach, which perhaps may be fairly applied to all inflam- 
matory affections of the digestive tube. When inflammation of the 
stomach or any other portion of the intestinal canal has continued 
for some time, and when the disease has attained a certain degree 
of violence, the local symptoms may subside, and the gastritis or 
enteritis will be represented by disease of some other organ, by symp- 
toms of an affection of the brain or its investments, or by symptoms 
of disease of the lining membrane or parenchymatous tissue of the 
lung. I shall endeavour to explain this. Here is a case taken from 
the Clinique Medicate of Andral. 

" A middle aged man, four days before his entrance into the hos- 
pital, w T as seized with bilious vomiting, epigastric pain, and fever. 
(Here is a certain case of gastritis.) In about twenty four hours 
after the invasion of these symptoms, he first perceived a difficulty 
in depressing the lower jaw, and a violent trismus was established, 
which continued for the two following days ; at the end of this time 
he entered the hospital in the following state: — trismus, the head 
drawn backwards and forcibly retained in this position by the 
muscles which are inserted into the occipital region; rigidity of all 
the extremities ; abdomen hard as a board; intellect perfect. Not- 
withstanding the trismus, the patient could articulate with sufficient 
distinctness to give the above account of his case. From the time 
when the first tetanic symptoms appeared the vomiting and epigastric 
pain ceased. He died on the evening of his admission. On dis- 
section no appreciable alteration of structure was found in the brain 
or spinal marrow ; the meninges of the brain were very slightly 
vascular, but those of the spinal marrow pale. The whole surface 
of the stomach presented an intense red colour, which was at first 
concealed by a thick layer of mucosities. The remainder of the 



DISEASES OF THE DIGESTIVE SYSTEM. 



47 



digestive tube was perfectly healthy, and the thoracic organs were 
natural." This may be called a case of tetanus ; and itis a curious 
fact, that when the tetanic spasms came on, the vomiting and other 
symptoms of gastritis subsided. Now this is what I wish to direct 
your attention to. A man dies with symptoms of an affection of 
the brain, the head is opened after death, there is no trace of cere- 
bral disease found, but the whole surface of the stomach is discovered 
to be in a state of intense inflammation. That the stomach was 
inflamed is proved by the vomiting and epigastric pain which ex- 
isted during life, as well as by the vascularity which was revealed 
by dissection ; and there can be no doubt that this condition was 
the result of an intense inflammation, as there was no other cause 
to produce it. 

Last year, a patient was admitted into the Meath Hospital, la- 
bouring under violent maniacal excitement, his eyes bloodshot, and 
his aspect ferocious. He had thirst, a dry fissured tongue, a quick 
weak pulse, and constipated bowels. There was no epigastric ten- 
derness, no vomiting, in fact none of the prominent symptoms of 
gastritis complained of. On the third day the belly was slightly 
tender and tympanitic. The cerebral symptoms increased so as 
to require the use of the strait waistcoat, and continued with violence 
until a short time before death, which occurred on the eighth day. 
On dissection there was no appearance of inflammation found 
in the brain or its membranes, but there was a vast extent of disease 
in the digestive tube. The splenic extremity of the stomach pre- 
sented several patches of vascularity, and its mucous coat was 
softened ; the lower half of the ileum, the caecum, and part of the 
ascending colon, were in a state of intense inflammation, and dotted 
all over with numberless ulcerations. 

You observe of what importance the knowledge of these facts 
will be to you in practice, and how much it should become the 
object of your study, since you will thereby be able to make the 
diagnosis of gastritis from the sympathetic relations, though the 
usual symptoms are more or less absent. Even in cases of this 
kind, in which the symptoms have subsided on the appearance of 
these sympathetic irritations, the judicious practitioner will not be 
diverted from directing his attention to the source of the original 
mischief ; nor will he, because the local symptoms have disappeared, 
conclude that the disease has therefore been removed from the sto- 
mach. Many examples of this apparent transition of disease are 
to be seen in cases of children, in which an inflammation of the 
upper part of the digestive tube frequently similates hydrocephalus, 
and where the headache, delirium, and intolerance of light, are com- 
pletely removed by the application of leeches to the epigastrium. 
I have seen this occur many times, and would entreat your particular 
attention to it. I believe many children are lost from the want of 
correct notions on this subject on the part of their medical attend- 
ants.* The phenomena present in such cases are certainly those 

* [Unless we are fully acquainted with the precursory symptoms and the ad- 
mitted cause, as external injury, sun-stroke, &c., of cerebral affections, whether 



48 



STOKES'S THEORY AND PRACTICE. 



which characterize hydrocephalus ; but you should always investi- 
gate them with care, and ascertain whether the disease has com- 
menced with symptoms of inflammation of the mucous membrane 
of the stomach, or bowels ; and if you find that it has originated 
in this way, and that the cerebral symptoms have not gone too far, 
direct your treatment in the first place to the digestive tube. 
It is extraordinary how rapidly all the symptoms of apparent 
cerebral disease subside under this plan of treatment. I must 
mention here to you a very remarkable case of enteritis, which 
simulated local disease of the substance of the brain. A girl 
who had received an injury was admitted into the Meath Hos- 
pital ; she was treated with purgative medicines, and was " dis- 
charged cured /" In a few days afterwards she was re-admit- 
ted with pain in the head, and violent spasmodic contractions 
of the fore-arm, by which the fingers were bent so forcibly that 
the nails were driven into the hand. There was no thirst, vomit- 
ing, or abdominal tenderness. She died a few days after her 
admission ; and on dissection the brain was found perfectly healthy, 
the viscera of the thorax were in the normal state, the stomach 
presented nothing remarkable, but the ileum was almost one sheet 
of deep and recent ulcers. The result of this case is important, 
also, in another point of view. You know that spasmodic contrac- 
tions of the upper extremity are believed by certain pathologists to 
point out an inflammatory softening of the optic thalamus, and its 
prolongations. Here we had the symptom, at all events, without 
the corresponding lesion. 

I shall reserve the subject of sympathetic irritations of the respi- 
ratory system until Wednesday, when I expect to be able to finish 
the pathology and treatment of gastritis. 

manifested by delirious ravings, and jactitation or by convulsions, either in 
children or in adults, we shall find the gastric to be the safer pathology, and we 
ought to prescribe accordingly. Among other cases which might be related, I 
remember, very distinctly, that of a child between three and four years old, whom 
I found with flushed face, eyes shining and injected, and somewhat incoherent, 
and raving, with occasional spasms, short of convulsions. The mother of the 
patient thought it had been eating stramonium seeds. I believed, on inquiry, that 
it had made too free with cherries, and, accordingly, gave it an emetic, which 
made it throw up a goodly number of this fruit, and brought, in consequence, 
speedy and complete relief. The symptoms, a little before, would have justified 
bleeding, cold applications to the head, &c. 

A case which occurred under my observations, when I was yet a student of 
medicine in Virginia, made a permanent impression on my mind. A child, about 
two years old, had eaten of some fruit, the kind I do not remember, which caused 
violent convulsions, followed by coma and strabismus, in which state it remained 
for three days. At last, to the wonderment both of its physician, who barely 
hoped, and of the attending crones, who had been sighing and croaking death 
around its cradle, it revived, and ultimately recovered its health. 

In other cases, although the offending substance may have been ejected from 
the stomach, this organ soon after becomes inflamed, and the cerebral symptoms 
return with violence. Then must we have recourse to leeches to the epigastrium, 
and other means of removing the gastritis, and, in so doing, we shall find that 
there is a subsidence also of the disorder of the brain.— B.] 



PATHOLOGY AND TREATMENT OF GASTRITIS. 49 



LECTURE IV. 

Gastritis — No one symptom decidedly indicative of the particular condition of any 
organ — Sympathetic irritation liable to terminate in organic disease — Sympathetic 
relations as connected with the viscera of the thorax — Treatment of simple acute 
gastritis — Antiphlogistic remedies — Purgative medicines injurious — Enemas and 
injections — Use of ice beneficial — Effervescing medicine hurtful. 

You recollect that at our last meeting I endeavoured to lay 
before you some of the general facts connected with the pathology 
of gastritis, and showed you that the statement made by Broussais, 
that inflammation of the mucous membrane of the stomach is 
always accompanied by a similar affection of some part of the 
intestines, has not been confirmed by the investigations of more 
recent observers ; but, on the contrary, that their experience goes 
to disprove, in various instances, the validity of this assertion. 
But, when I say that this statement has been disproved, it is only 
as taken in the general and extended sense. The fact of their fre- 
quent co-existence has been proved ; the statement that they are 
always associated has been found incorrect. Another thing con- 
nected with this, which has been also established by repeated 
observation, is, that the cases in which they are commonly com- 
bined are those in which a secondary affection of the mucous sur- 
face of the digestive tube comes on during the course of a fever ; 
so that, if in fever a gastritis supervenes, you^will commonly have 
enteritis ; or if the fever be complicated with enteric inflammation, 
the mucous surface of the stomach will partake in the diseased 
action. 

I have described some of the more prominent symptoms of gas- 
tritis, and directed your attention not only to the ordinary symp- 
toms, as mentioned in books, but also to others which have either 
been passed over, or slightly noticed, by authors ; as, for instance, 
dysphagia, oppression and sense of constriction about the prse- 
cordia, globus, pains relieved by cold and acid drinks, &c, and 
that obstinate hiccup, which, in cases where there is reason to 
suspect gastritis, marks inflammation of the cardiac orifice of the 
stomach. I stated that hiccup alone does not prove the existence 
of inflammation of the cardiac orifice of the stomach, unless where 
symptoms, indicative of gastric inflammation, prevail at the same 
time. I laid before you the actual state of the case with respect to 
the value and certainty of diagnosis, as derived from an inspection 
of the tongue ; and showed you that no reliance can be placed on 
it, since it has been proved that we have the most opposite condi- 
tions of the digestive tubes, accompanied by a similar condition of 
the tongue ; and that there is no peculiar modification of the one, 
corresponding exactly and constantly with any peculiar modifica- 
tion of the other. The conclusion to be deduced from these facts 
is, that in the treatment of inflammatory affections of the digestive 



50 



STOKES'S THEORY AND PRACTICE. 



tube, we are not authorized, and would frequently err, in taking 
the tongue alone as our guide in practice ; and you may lay down 
this as a rule, and an important one : — if we look through the 
whole range of the history of medicine, we shall scarcely be able 
to point out any symptom which, taken singly, is decidedly indica- 
tive of any one particular condition of an organ. You will find 
that this proposition is not only extensive in its scope and relations, 
but also of extreme value in its application. You will commonly 
hear persons saying, that is such a disease, for this symptom is pre- 
sent, and that is such a disease, for such a symptom is extremely 
well marked. But there is no single symptom which points out, 
with certainty, any peculiar condition ; and to arrive at a just and 
well-grounded diagnosis, you must always take the whole group 
of existing phenomena, connect the lights which they collectively 
throw upon the case, and then make a cautious decision. It may 
be objected to this that there are particular signs ; as, for instance, 
the stethoscopic, which point out distinctly particular states of 
organs. It is said that gargouillement is decidedly indicative of 
a phthisical cavity, that cegophony points out a particular stage of 
pleuritic effusion, and that metallic tinkling is an unequivocal 
proof of pneumothorax. This, however, is not the fact ; even in 
these cases you are not authorised to depend on any sign or symp- 
tom taken alone. If you ground your decision on any individual 
sign, you will very often fail in arriving at the truth. 

I showed yes that the sympathetic irritation of gastritis varied 
according to the peculiar character of the disease, and the habit 
and degree of susceptibility of the patient; that, generally speak- 
ing, the more intense the disease is, the more numerous are its 
irritations ; but that, in all cases, they are considerably modified 
by predisposition (I use this term for want of a better), the sympa- 
thetic irritation being reflected on the lungs in cases where these 
organs are naturally unsound, and on the brain, where the patients 
have a tendency to disease of that organ. I endeavoured, also, to 
impress on you the fact, that these irritations are at first functional ; 
but when long continued, or marked by extreme severity, they are 
very apt to terminate in organic disease. I illustrated this point 
by several examples; I shall give a few more of this kind before I 
enter on the treatment of gastritis. 

If a patient labouring under acute gastritis has a bad cough, if 
respiration be very much hurried, and the distress of the chest 
great, and that these symptoms are overlooked or neglected, you 
will find that the cough, which was at first only a result of func- 
tional disease, will at last point out an organic affection of the lung. 
Again ; let a patient, labouring under gastritis, have severe head- 
ache, restlessness, and irritation ; suffer these symptoms to go on 
and increase in violence, and the great probability is, that they will 
terminate in arachnitis. The obvious deduction from these facts 
is, that when a sympathetic irritation has existed for some time in 
a state of considerable intensity, it is very probable that there is 



PATHOLOGY AND TREATMENT OF GASTRITIS. 



51 



more or less of organic derangement produced, and we are not to 
expect to be able to remove it by merely attacking the original seat 
of the disease. 

The last great rule which I endeavoured to impress upon you 
was, that where these sympathetic irritations, these affections of 
the nervous, respiratory, and circulating systems, were extremely 
well marked, the ordinary local symptoms were more or less want- 
ing, but that this does not by any means imply the subsidence of 
the original disease. This is a most important law in pathology. 

In my last lecture, I entered into a detail of the sympathetic 
irritations connected with the brain and other parts of the nervous 
system ; to-day we shall consider the sympathetic relations, as con- 
nected with the viscera of the thorax. If you look to the cases of 
acute gastritis, mentioned in works on toxicology, you will find 
that in cases of gastritis, produced by swallowing corrosive poi- 
sons, the patient has often frequent hard cough, the breathing is at 
first hurried, then becomes protracted and laborious, and that death 
is generally ushered in by tracheal rattle. The same symptoms 
are observed in cases of acute idiopathic gastritis ; hurried breath- 
ing, extraordinary hard and almost laryngeal cough, sometimes 
occurring in paroxysms, sometimes constant. For the first few 
days it is, generally speaking, dry ; as it progresses, there is more 
or less expectoration. At first, it is the result of sympathy ; there 
is as yet no organic affection of the respiratory system, and the 
disease is purely functional ; still it is of importance, and entitled to 
your particular attention, because, in consequence of the apparent 
identity of the symptoms, it is often mistaken for disease of the 
substance of the lung, or its mucous lining. The existence of a 
gastritis is frequently overlooked ; the ordinary symptoms of pain 
in the region of the stomach, tenderness on pressure, and thirst, are 
overlooked, and the sympathetic relations alone are attended to. 
Observe what mischief may result from this error. The treatment 
of acute affections of the lining membrane, or parenchymatous 
tissue of the lung, is very different from the treatment of a gas- 
tritis. In the one case bleeding is necessary ; in the other, its 
efficacy may be doubtful, or the practice even dangerous. In one, 
tartar emetic is one of the best and most expeditious means of 
effecting a cure; in the other, the use of antimonials has the worst 
effect. It will strike you that in such cases percussion and the 
stethoscope are of inestimable value. You are called to attend a 
patient in fever, you find he has cough, hurried breathing, and 
perhaps pain in the chest ; from a consideration of the history of 
the case, and the primary symptoms, you have reason to think the 
case is one of gastritis, and you wish to know whether the symp- 
toms be purely sympathetic, or caused by organic disease of the 
lung. In such a case, a person without the knowledge of the 
stethoscope is completely helpless, and unable to decide the point. 
This I assure you, is a very common case, and should be a strong 
inducement to the study of the stethoscope. What advantage does 



52 



STOKES'S THEORY AND PRACTICE. 



a knowledge of the stethoscope give ? It leads to the formation of 
an accurate diagnosis ; it points out either that there is no disease 
in the lung, or if there be, that it is not sufficient to account for the 
symptom, and therefore that you should look for its cause in some 
other situation. You find a person with laboured and rapid 
breathing, perhaps fifty or sixty in a minute ; you are struck with 
the apparent lesion of the respiratory system, but on percussing the 
chest, and using the stethoscope, you find the respiration perfectly 
clear, or perhaps a slight bronchitis, insufficient to account for such 
violent symptoms. Where such phenomena are observed, you 
will often find that they are connected with a gastritis, particularly 
where there is fever, and the local signs of a gastric inflammation. 
I can tell you, from a most extensive experience, that in such cases 
you can inform the patient's friends, that the most sudden and 
decided relief will be experienced from the use of iced water, and 
the application of leeches to the epigastrium. You can have 
hardly an idea of the rapidity with which all the symptoms of pul- 
monary irritation are removed by this practice. Cases of this 
extraordinary sympathetic irritation are very common in children, 
but you will also frequently meet with them in adults. 

I have been called to decide the question, whether a disease was 
pneumonia or gastritis, where there was a difference of opinion 
between two practitioners. Now, it is very easy to come to a 
proper decision in such cases. There is one point which you 
should always hold in view, and that is, the length of time the 
symptoms have lasted. If symptoms of pulmonary disease have 
been going on for four or five days, and, at the end of that time, 
you find that there is no perceptible organic disease of the lung, 
you may be certain that it is gastric irritation ; because if it were 
organic disease of the lung, it would have shown itself before that 
time, and could be detected by percussion or by the stethoscope. 
We have had many cases of these sympathetic irritations of the 
lungs in the Meath Hospital, which recovered under the treatment 
for gastritis ; and where the patients, by some excess or error in 
diet, brought on the pulmonary symptoms again, they were 
removed a second time by putting them on a low diet. Before I 
quit this subject, I wish to make one- remark, by waj' of caution. 
When you have discovered the existence of those sympathetic 
irritations, you should not be thrown off your guard, and consider 
them only as functional affections. You should examine the next 
day and the day after, for you may find that in a very short space 
of time actual disease of the lung has taken place. You should 
be, therefore, watchful, and never omit making a daily examination; 
for if the sympathetic irritation be severe, it is very apt to run into 
actual organic disease. 

We now come to speak of the treatment of simple acute gastritis. 
Here there are three principal indications. One of these is to 
remove inflammation as speedily as possible. You cannot, as 
under other circumstances, leave this disease to nature; the organ 



PATHOLOGY AND TREATMENT OF GASTRITIS. 53 



affected is one of the utmost importance to life ; and if yoa do not 
cut it short at once, a typhoid state comes on, to which the ordinary 
and efficient means of antiphlogistic treatment are inapplicable. 
The first indication, then, is to cut short the inflammation as 
speedily as possible. The next thing is to prevent the introduction 
of anything into the stomach which will excite the physiological 
action of that viscus. You are aware, that while the stomach is 
engaged in the process of digestion, its vascularity is very much 
increased, and that this, which in health is merely a physiological 
condition, is unaccompanied by any kind of danger. But in a state 
of disease it proves a source of violent excitement, and superadds 
very much to the existing inflammation. You must, therefore, be 
extremely cautious with respect to what enters your patient's 
stomach, and carefully remove everything capable of adding to 
the excitement which always attends gastritis. The third indica- 
tion in the treatment is to modify and remove the sympathetic or 
secondary irritations. 

Now 1 shall suppose that we have to treat a case of simple acute 
gastritis, not produced by the swallowing of corrosive poison, or 
indigestible food. Here we have a patient labouring under violent 
inflammation of one of the most important organs in the body ; 
and the question is, are you to adopt the ordinary and usual mode 
of stopping inflammation by opening a vein in the arm? I must 
here state, that we are very much in want of a series of well- 
established facts to guide our practice on this point, and to inform 
us how far general bleeding is useful in acute inflammation of the 
stomach. At the present period, the question is by no means 
settled, and the practice is uncertain. I believe, however, that 
when we are called in at an early period of the disease, where the 
patient is young and robust, the stomach previously healthy, the 
fever high, and the pain great, we may have recourse to general 
bleeding with advantage; bearing this in mind, however, that yoa 
are not to expect to cut short the inflammation by the use of the 
lancet. Inflammations of the mucous membrane of the stomach 
and bowels, and perhaps of the lungs, are not to be overcome at 
once by the lancet ; the only cases in which you can expect to 
cut short an inflammatory attack, are those in which the paren- 
chymatous tissue of an organ, or its serous membrane, is affected. 
This is a general and important law. You will often be able to 
cut short a hepatitis or pneumonia by a single bleeding, but you 
will not by the same means be able to repress a bronchitis or 
an inflammation of the mucous membrane of the intestines. If 
you bleed in gastritis, bleed at an early period ; not too largely, or 
with the expectation of cutting short the inflammation, but in order 
to prepare your patient for the grand agent in effecting a cure — 
local bleeding. This is the principle on which you are to employ 
the-lancet. 

In the treatment of gastritis there is nothing more useful, 
nothing more decidedly efficacious, than the free and repeated 

G 



54 



STOKES'S THEORY AND PRACTICE. 



application of leeches, whether the case be idiopathic, or produced 
by the swallowing of a corrosive poison. In this treatment of 
acute gastritis, you will frequently see, perhaps, the most striking 
instances of the rapid and decided utility of medical treatment ; 
you will see the vomiting subside almost immediately, the epigastric 
pain and tenderness disappear, the cough and headache relieved, 
the fever subside, and the tongue change, after the application of 
leeches. To remove these symptoms, the best and most effectual 
means are leeches ; and these must be applied again and again, 
according to the duration and obstinacy of the symptoms. Here I 
wish to make one remark of importance. From an opinion, very 
prevalent in former times, that pain and inflammation were insepa- 
rable, the older practitioners thought that when the pain ceased 
the inflammation also ceased ; and hence many of our predecessors, 
and I fear some of our cotemporaries, never think of reapplying 
leeches, no matter what the existing symptoms may be, if pain has 
been relieved by the first application. Nothing is more erroneous 
than this practice. It frequently happens that the pain and epigas- 
tric tenderness are removed by the first application of leeches, but 
the breathing is still quick, the fever high, and the thirst ardent. 
So long as these symptoms remain, the inflammation of the 
stomach is still going on. The mere subsidence of pain or tender- 
ness of the epigastrium should never prevent us from resorting to 
the application of leeches. In leeching the belly for inflammation 
of the stomach or bowels, it is a common practice to apply a 
poultice over the leech bites, with the view of getting away as 
much blood as possible. I am not inclined to approve of this 
practice. The weight of a poultice is frequently troublesome, and 
the heat produced by it disagreeable; the patients desire cold, and 
for this purpose they will often throw off their bed-clothes, feeling 
a degree of relief from exposing the epigastrium to a stream of 
cool air. Some practitioners have applied pounded ice over the 
stomach with good effects, and we see it frequently applied to the 
head with the same results in cases of encephalitis. Again : the 
application of poultices causes an oozing hemorrhage, the amount 
of which it is impossible to calculate, which is often hard to be 
arrested, and which, in debilitated persons and children, has the 
effect of lessening the powers of life without removing the original 
disease. It is much better to leech again and again than to do 
this. Where there is not much epigastric tenderness, you may 
apply a cupping-glass over the leech bites with advantage, as you 
can get away as much blood as you choose, and the tendency to 
after-hemorrhage from the leech bites is diminished by the applica- 
tion of the cupping-glass. In very young subjects, the tendency 
to obstinate hemorrhage from leech bites is so great, that many 
practitioners are afraid to use leeches, and I believe some children 
have been sacrificed to this fear. The best mode of managing 
this is, if the leech bites cannot be stopped by the ordinary means 
(and in very young children they seldom can), to stop them at once 



PATHOLOGY AND TREATMENT OF GASTRITIS. 55 



by the application of caustic. Do not lose time in trying to arrest 
the flow of blood with flour, or lint, or sticking plaster ; wipe the 
blood oft' the bite with a piece of soft dry lint, plunge into it a piece 
of lunar caustic, scraped to a point, give it a turn or two, and the 
whole thing is settled ; and you can generally go away with the 
agreeable consciousness of having prevented all further danger, 
and without being uneasy lest your patient should bleed to death in 
your absence. 

With respect to the management of the bowels in acute gastritis, 
a few observations will suffice. You will always have to obviate 
the effects of constipation; both in the acute and chronic forms of 
the disease there is always more or less constipation ; in fact, the 
same condition of the bowels is generally observed in both. Now, 
if you attempt to relieve this constipation in acute gastritis, by 
administering purgatives, you will most certainly do a vast deal of 
mischief. Nothing can exceed the irritability of the stomach in 
such cases; the mildest purgatives are instantly rejected, even cold 
water, or effervescing draughts are often not retained, and a single 
pill or powder is frequently thrown up the moment it is swallowed.* 
Under such circumstances, it is plain that the administration of 
purgative medicine is totally out of the question. Even though 
the stomach should retain the purgative, you purchase its opera- 
tion at too dear a price ; for it invariably proves a source of violent 
exacerbation, kindling fresh inflammation in an organ already too 
much excited. In this state of things, the best thing you can 
employ to remove constipation is a purgative enema, repeating it 
according to the urgency or necessity of the case. Where there is 
no inflammation in the lower part of the intestinal canal, you may 
employ injections of a strong and stimulating nature, with the 
view not merely of opening the bowels, but also of exercising a 
powerful revulsive action. I shall mention here an interesting 
fact, proving that stimulant injections have a decided revulsive 
effect ; and that their influence extends not only to other portions 
of the intestinal tube, but also to distant parts, of the system. In 
South America, where, from the heat of the climate, and the preva- 
lence of bilious affections, sick headache is a very common and 
distressing symptom, a common mode of cure is to throw up the 
rectum an extraordinary enema, composed of fresh capsicum, and 
other aromatic stimulants. The irritation which this produces 
acts as a very efficacious and speedy revulsive, causing the almost 
immediate removal of the cerebral symptoms. 

In those cases of gastritis, where not only purgatives, but even 
the mildest substances, are rejected, the plain common-sense rule 
is to give nothing. Where cold water is borne by the stomach, it 

* [I have, in some cases, after venesection and leeching, given calomel with 
advantage in gastritis: — its action on the duodenum, liver, and large intestine, 
renders it decidedly revulsive. I prefer it alone, to its union with opium, 
under these circumstances. I can speak favourably, also, of a laudanum enema 
in gastritis after sanguineous depletion.— B.] 



56 



STOKES'S THEORY AND PRACTICE. 



may be taken in small quantities, as often as the patient requires 
it. Solid ice, too, may be given with decided benefit. There is a 
mistake which prevails with respect to the employment of ice in 
gastritis, which I wish to correct. Some persons objected to this 
use, and reason in this way: — persons who have taken a quantity 
of cold water, or ice, when heated by exercise, have been frequently 
attacked with gastritis and fever, and consequently the use of these 
substances must be attended with danger in case of gastric inflam- 
mation. This, however, is false reasoning ; you need not be afraid 
to order your patient ice, ad libitum ; depend upon it, there is no 
danger in employing either ice or cold water in gastritis. There 
is nothing so grateful to the patient as ice. Let a quantity of it be 
broken into small pieces, about the size of a walnut; let your 
patient take one of these pieces, and, having held it in his mouth 
for a few moments to soften down its angles, let him swallow, it 
whole. The effect produced by this on the inflamed surface of 
the stomach is exceedingly grateful, and the patient has scarcely 
swallowed one portion when he calls for another with avidity. It 
will be no harm if I should here mention to you a secret worth 
knowing. There are few things so good for that miserable sick- 
ness of the stomach, which some of you may have felt after a 
night's jollification with a set of pleasant fellows, as a glass of ice; 
Byron's hock and soda-water are nothing to it. 

After the first violent symptoms of the disease have been sub- 
dued, I believe the very best thing which can be given is cold 
chicken broth. The point which we are always to keep in view 
is, to remove inflammation from the stomach, and this should regu- 
late the use of everything taken into the stomach. I believe we 
might derive much advantage from anodyne injections in gastritis. 
I cannot say that I have ever employed them in such cases ; but 
if I were to reason from their utility in other forms of abdominal 
inflammation, I should be induced to look upon them as entitled to 
some consideration. There is another point to which I will briefly 
advert. In the treatment of acute gastritis, there is nothing more 
commonly used than effervescing draughts ; yet I have frequently 
seen them produce distinct irritation of the stomach. In cases 
where gastric irritability is excessive, I would not advise you to 
give effervescing draughts, or if you do, watch their immediate 
effect; see how the first one has agreed with the stomach before 
you venture to give any more. Patients labouring under this dis- 
ease should be kept extremely quiet, as frequently a slight motion 
brings back the vomiting. Everything which is swallowed should 
be in small quantity; a large quantity of any substance frequently 
causes a return of the vomiting, by distending and irritating the 
stomach. One of the best things you can give, and the best way 
of giving it, is iced lemonade, giving a tablespoonful from time to 
time. The extremities, which are generally cold in cases of intes- 
tinal disease, should be swathed in warm flannel. 

I shall mention here a rule which should be carefully observed 
in the after treatment. A patient has recovered from the violent 



PATHOLOGY AND TREATMENT OF GASTRITIS. 57 

symptoms of the disease; the fever, thirst, pain, epigastric tender- 
ness, and sympathetic affections, have subsided ; but he still is con- 
fined to bed, and in a state of great debility. Some patients, under 
these circumstances, have been unfortunately lost by allowing 
them to sit up in bed, or on the night chair. The nurse will some- 
times, through ignorance, suffer a patient, thus enfeebled, to risk 
his life by sitting up in bed ; sometimes, during the course of the 
night, she is overcome by sleep ; the patient has a call to empty 
his bowels ; and not wishing to disturb her, attempts to get up, and 
is found, in some time afterwards, sitting on the night chair quite 
dead. This is an unfortunate termination for the physician as well 
as the patient. A German author, Hoffmann, has written a treatise 
on the danger of the erect position after acute diseases ; and in the 
course of the work, which is a very interesting one, he cites 
numerous instances of its bad effects. Not very long since, a 
patient was lost in the Meath Hospital, by the nurse allowing him 
to sit up after a severe attack of enteritis. Such, also, was the 
melancholy cause of death in the case of the late Mr. Hewson, 
one of my best and earliest friends. He got a severe attack, which 
was subdued with difficulty, and his convalescence was doubtful 
and protracted. One night, in the absence of his attendant, he got 
up for the purpose of emptying his bowels, and was found, some 
time afterwards, on the night chair, nearly dead. He was imme- 
diately brought back to bed, and the necessary means employed 
to relieve him, but without much benefit, for he never recovered 
the effect produced on his debilitated frame.* 



LECTURE V. 

Pathology and treatment of gastritis — Application of blisters — Emetics can be seldom 
used in acute gastritis — Ha^matemesis and delirium tremens complicated with gas- 
tritis — Treatment of these affections — Dyspepsia, or chronic gastritis — Hypochon- 
driasis — Termination of chronic gastritis. 

There is one point connected with the treatment of gastritis 
which I have not yet touched upon — the use of blisters ; and as 
this is the first time I have spoken of them, I shall make a few 
remarks on their general application. 

It is a great error to think that blistering is a matter of course in 
inflammatory diseases, or that the proper period for their applica- 
tion should not be carefully marked. It is a common idea, that if 
a blister does no good it will do no harm ; that it is probable some 

* [Not only in cases of great prostration from hemorrhage, cholera, &c., but 
in the advanced stage of all diseases of an acute character, the patient should be 
prevented from rising or even sitting up in bed. A bed-pan slipped under him will 
be the substitute for a close-stool; nor should any foolish prejudice— a thing not 
uncommon with persons who have heretofore enjoyed good health, — prevent its 
use. — B.] 

6* 



58 



STOKES'S THEORY AND PRACTICE. 



benefit may result from its employment, and that you may try it 
at all events. I need not tell you that all this is wrong, and that 
we must be guided by exact principles in this as well as in every 
other part of practical medicine. I am afraid there is a great deal 
of loose reasoning and empirical practice connected with this sub- 
ject, even at the present day. Here is the general rule by which 
you should be invariably guided. No matter what kind of disease 
you have to deal with, if it be inflammatory, blistering in the early 
stage of it is decidedly improper. I might amplify this rule, and 
say, that if the disease be inflammatory and in its early stage, or if, 
under such circumstances, the symptoms require the general or 
local abstraction of blood, blisters cannot be used with propriety. 
The truth is, that many persons take a very limited view of this 
subject; they look upon blisters as merely revulsive agents, which, 
by their action on the surface, have the property of diminishing 
visceral inflammation. This I am willing to allow is true to a 
certain extent, but there is abundant evidence to prove, that blisters 
have sometimes a direct stimulant effect on the suffering organ. 
That this occasionally occurs has been established by many facts 
in medicine ; and I have not the slightest doubt that the application 
of a blister over an organ in a state of high inflammatory excite- 
ment will certainly be productive of injurious consequences.* 
But if you apply them at the period when stimulation is admissible 
and useful, (and there will always be such a period in every inflam- 
mation,) you then act on just principles, and will generally have 
the satisfaction of finding your practice successful. The greatest 
empiricism is sometimes practised in the application of blisters to 
the head in acute inflammation of the brain. You will see, in Mr. 
Porter's admirable work on the Pathology of the Larynx, how 
strongly he is opposed to the early use of blisters in acute laryn- 
gitis. Dr. Cheyne, also, may, among many others, be quoted in 
support of this doctrine. 

If there is one system more than another likely to be injured by 
early blistering, it is the digestive. Broussais says that blisters 
should not be applied in any of the stages of acute gastro-enteritis, 
and that in the early stage their application is the very height of 
malpractice. I do not go so far as to say that they should not be 
applied in any period of the disease, for when the skin is cool, the 
pulse lessened, and the local inflammation so far reduced as not to 
require the abstraction of any more blood, I think you may employ 

* [Not only in primary gastritis, but, also, in gastritis in fever, some practi- 
tioners, either from not fully recognising the nature of the disease, or not appre- 
ciating the operation of blisters, are in the habit of applying them forthwith, so 
soon as the patient complains of heat and pain or tenderness in the epigastrium. 
This is bad practice in a double sense ; bad in itself, as tending to aggravate the 
disease; and bad indirectly, by preventing the application of leeches, and of ice or 
cloths immersed in cold water. We cannot afford to give away the epigastric surface 
in this manner, in the first stage of either gastritis, gastro-enteritis, or of fevers 
generally. The judicious practitioner will regard a blister as among the remedies 
to be the last employed in most acute diseases. — B.] 



PATHOLOGY AND TREATMENT OF GASTRITIS. 59 



them with very considerable advantage. I shall again return to 
the subject of blisters ; and will for the present merely remark, 
that blistering is almost always mismanaged, in consequence of 
persons who apply them being ignorant of their stimulating effects 
on organs. They generally allow them to remain on too long, and 
the consequence of this is often violent excitement of the organ 
over which they are applied, great constitutional irritation, stran- 
gury, and bad sores. The best mode of using them is to direct 
the person who prepares the blister to cover it with a piece of 
silver-paper before it is applied, and having put it on with the 
paper next the skin, to let it remain until a decided sense of smart- 
ing is produced, when it should be immediately removed. By 
adopting this plan, you will save yourself and your patient a great 
deal of inconvenience; you will have no strangury, stimulation of 
the whole economy, or excessive local irritation, and the inflamed 
surface will heal kindly. The mode (too often practised) of apply- 
ing a blister sprinkled all over with an additional quantity of pow- 
dered cantharides, and leaving it on for twelve, twenty-four, or 
even thirty-six hours, particularly in the case of females, is nothing 
better than horse doctoring. During a seven years' experience in 
the hospital at Tours, Bretonneau, by attending to this principle, 
never had a case followed by these troublesome symptoms, and 
yet he never failed in producing the necessary degree of counter- 
irritation. The active principle of cantharides, being soluble in 
oil, exudes through the silver-paper in sufficient quantity to pro- 
duce the necessary effect on the skin, without exposing the patient 
to the risk of having too much irritation excited by the direct ap- 
plication of the blistering plaster to the cutaneous suface.* 

With respect to emetics, I need not tell you that they can be very 
seldom used in acute gastritis, and that all your efforts should be 
directed to obviate and remove vomiting. But are we to interdict 
their use altogether? There are some few cases where we are 
compelled to use them ; as, for instance, in cases of acute gastritis 
caused by swallowing corrosive poison, or by the irritation of indi- 
gestible food remaining in the stomach. The first step to be taken 
in a case of corrosive poisoning, is to evacuate the stomach. In the 
same way, when you are called to treat a case of gastritis produced 
by indigestible aliment, you must commence by giving an emetic. 
But even here the emetic is admissible only in the early period ; 
and you should never trust to its operation for removing the gas- 
tritis altogether, unaided by other therapeutic means ; nor are you 
to conclude that because you have produced vomiting you have 
succeeded in curing the disease. The same principles apply to the 

* [Mr. Trousseau has recently recommended an ethereal extract of cantha- 
rides, which is obtained from, the action of sulphuric ether on the powder of can- 
tharides. Portions of blotting paper of various sizes are imbibed with this extract 
and form so many blisters. Blistered surfaces may be kept running by applying 
to them the extract of cantharides mixed with yellow wax in the proportion of the 
former of T ^ to ^xh. — B.] 



60 



STOKES'S THEORY AND PRACTICE. 



use of purgatives in enteritis as to emetics in gastric inflammation ; 
we should never have recourse to them except where inflammation 
is kindled and kept up by the presence of irritating matter. 

There are two cases in which certain affections are complicated 
with an acute gastritis; and as these complications are not suffi- 
ciently known, and have been scarcely noticed by sytematic writers 
on gastritis, I am anxious to draw your particular attention to 
them. One of these is hcematemesis, the other that disease which 
has been termed delirium tremens. There are cases of vomiting 
of blood, which are little more than acute gastritis, in which there 
is a copious secretion of blood from the mucous surface of the sto- 
mach. Vomiting of blood may arise from various causes. It may 
be vicarious, as in the case of females, where the menstrual flux is 
suppressed ; it may be accidental, as from the rupture of a blood- 
vessel ; or it may be caused by mechanical obstruction to the 
circulation, either in the liver, spleen, heart, or lungs. But there 
is a species of gastritis, in which there is a copious vomiting of 
blood ; or there is an hsematemesis, of which the cause is gastric 
irritation. How are you to recognise this form of the disease ? — 
The patient is vomiting blood ; but then he has fever, hot skin, 
and excited pulse. Again, you will see some peculiar modification 
of the tongue ; you will find ardent thirst and longing for cold 
drinks ; you will observe fulness and tenderness of the epigastrium ; 
you may have severe local pain ; finally, you will have all these 
symptoms occurring in a person who, previously to the attack, 
exhibited nothing capable of accounting for the hsematemesis. 
Here, then, we have an hemorrhagic gastritis, very little known, 
and too often improperly treated. The ordinary practice, in such 
cases, is to give astringents. Astringents are very good and useful 
where they are clearly indicated; but there are many forms of 
disease where their routine employment is productive of a great 
deal of mischief; and I believe lives are sometimes lost by looking 
upon this affection as a simple hasmatemesis, and by practitioners 
contenting themselves with the use of astringents. But where you 
have the symptoms of this form of gastric irritation present, where, 
in addition to the vomiting of blood, you have fever, and thirst, 
and hot skin, and pain, and epigastric tenderness, you may be sure 
that it is a gastritis, and that the best treatment is leeches, iced 
water, and the other means recommended in the treatment of gastric 
inflammation. It may happen that, under this treatment, the vomit- 
ing of blood will not entirely subside ; but the pain, the thirst, the 
fever, and epigastric tenderness will subside, and then you can 
with propriety give astringents. The best thing you can do in the 
commencement is to leech freely, give iced lemonade, and cold 
water ; prohibit everything purgative, stimulant, or astringent ; and 
then, when you have reduced inflammation, if the haematemesis 
continues, have recourse to astringents. 

A few words now with respect to the other complication — delirium 
tremens. You have all seen cases of delirium tremens, but you 



PATHOLOGY AND TREATMENT OF GASTRITIS. 



61 



are not, perhaps, aware that it arises under two opposite classes of 
causes. In some cases, a patient who is in the habit of taking 
wine or spirituous liquor every day in considerable quantities, meets 
with an accident or gets an attack of fever. He is confined to bed, 
put on an antiphlogistic diet, and in place of wine or whiskey- 
punch gets whey and barley-water. An attack of delirium tremens 
comes on, and symptoms of high cerebral excitement appear. 
Another person, not in the habit of frequent intoxication, takes to 
what is called a fit of drinking, and is attacked with delirium 
tremens. In the first case the delirium arises from a want of the 
customary stimulus, in the second from excess. In each the cause 
of the disease is different ; and, consequently, with this view of the 
subject, it would be a manifest departure from sound practice to 
treat both cases in the same way. Yet, I believe, this error is 
frequently committed, even by persons whose authority is high in 
the medical world, and is part of a system not yet exploded — the 
system of prescribing for names and not for things. The patient is 
treated for a disease which has been called delirium tremens, the 
present symptoms are only attended to, and the cause and origin of 
the affection are overlooked. What are the true principles of treat- 
ment? — In the first variety/ where the delirium is produced by a 
want of the customary stimulus, there is no doubt that patients have 
been cured by the administration of the usual stimulants, by giving 
them wine, brandy, and opium. Indeed, this seems to be the best 
mode of treating this form of the disease. But is it proper or ad- 
missable in the second variety, where the delirium is caused by an 
occasional excess in the use of ardent spirits ? — Certainly not. Yet 
what do we find to be the ordinary practice in hospitals when a 
patient is admitted under such circumstances? — A man, who has 
been attacked by delirium tremens after a violent debauch, is 
ordered a quantity of porter, wine, brandy, and opium ; and the 
worse he gets, the more is the quantity of stimulants increased. 
Now this practice seems to me as ridiculous as the old principle of 
treating a case of hydrophobia with a hair of the dog that bit. Let 
us consider what the state of the case is : — A large quantity of 
stimulant liquors have been taken into the stomach, the mucous 
surface of that organ is in a state of intense irritation, the brain 
and nervous system are in a highly excited condition fromr the 
absorption of alcohol, or in consequence of the excessive sympa- 
thetic stimulation to which they have been subjected. Are we to 
continue this stimulation ? — I think not. What would be the obvious 
and natural result? — Increased gastric irritation, encephalitis, or 
inflammation of the membranes of the brain. The supervention of 
inflammatory disease of the brain in delirium tremens is not under- 
stood by many practitioners, and they go on administering stimulant 
after stimulant, totally unconscious that they are bringing on decided 
cerebral disease. I have witnessed the dissections of a great, many 
persons who died of delirium tremens, and one of the most common 
results of the dissection was, the discovery of unequivocal marks of 



62 



STOKES'S THEORY AND PRACTICE. 



inflammation in the brain and stomach. Broussais considers all 
such cases as merely examples of gastritis, and ridicules British 
practitioners for inventing a "new disease;" but in this he is cer- 
tainly wrong, for there have been several cases in which no distinct 
marks of gastric inflammation could be discovered. In all cases, 
however, where the delirium supervenes on an excessive debauch, 
there is more or less of gastritis ; and though it may occasionally 
happen, that a patient under such circumstances may recover 
under the stimulant treatment, yet I am convinced that the physician 
will very frequently do harm by adopting it. 

This complication of delirium tremens with gastritis is also ex- 
ceedingly curious in another point of view, as it illustrates how 
completely the local symptoms are placed in abeyance, and, as it 
were, lost during the prevalence of strong sympathetic irritation. 
The patient's belly will not be tender ; the tongue may not be red ; 
the symptoms present may be indicative of a mere cerebral affec- 
tion, and yet intense gastric inflammation may be going on ail the 
time, and all the appearance of cerebral disease be quickly removed 
by treatment calculated to subdue a gastritis. Is this all theory'? 
No; for we have practised on this principle with the most extra- 
ordinary success in the Meath Hospital. We have seen cases of 
violent outrageous delirium subside under the application of leeches 
to the epigastrium, and iced water, without a single drop of lauda- 
num. I beg of you, if you meet with any cases of delirium tremens 
under such circumstances, to make trial of this mode of treatment, 
and record its effects, for it is important that they should be more 
extensively known. I have seen the whole train of morbid pheno- 
mena, the delirium, the sleeplessness, the excessive nervous agita 
tion, all vanish under the application of leeches to the epigastrium. 
In some cases where after the sleeplessness and delirium were re- 
moved by this practice, and the tremors alone remained, we have 
again applied leeches to the epigastrium, and succeeded in removing 
the tremors also. On the other hand, where a stimulant plan of 
treatment was employed, and the patients died, w r e have most com- 
monly found inflammation in two places, in the stomach, or in the 
brain or its membrane. The rule, then, is this — in a case of de- 
lirium tremens from the want of a customary stimulus, use the 
stimulant and opiate treatment ; but when it comes on after an occa- 
sional violent debauch, such remedies must be extremely improper. 
Adopt here everything calculated to remove gastric irritation. We 
have facts to show that most decided advantage may arise from 
the application of leeches, even where the symptoms of gastritis 
are absent.* 

* [In my own practice, I have met repeatedly with gastritis in women brought . 
on by the secret use of mixed liquors, cordials, &c. In one of these cases the 
attack was exceedingly severe, requiring the most energetic means for relief. 
As too often happens I was kept, at the time, in entire ignorance of its cause. 
Those vile compounds, true poisons, sold and drunk by the common people, and in 
greater proportion by females, under the name of cordials, are, to my knowledge, 
frequently causes of gastritis, both acute and chronic. — B.] 



PATHOLOGY AND TREATMENT OF GASTRITIS. 



63 



We come now to , consider chronic gastritis, an extremely in- 
teresting disease, whether we look upon it with reference to its 
importance, its frequency, or its Protean character. It is commonly 
called dyspepsia, and this term, loose and unlimited in its accepta- 
tion, often proves a stumbling block to the student in medicine. 
Dyspepsia, you know, means difficult digestion, a circumstance 
which may depend on many causes, but perhaps on none more 
frequently than upon chronic gastritis. In the great majority of 
dyspeptic cases, the exciting cause has been over stimulation of the 
stomach, either from the constant excess in strong highly-seasoned 
meats, or indulging in the use of exciting liquors. Persons who 
feed grossly, and drink deeply, are generally the subjects of dys- 
pepsia ; by constantly stimulating the stomach they produce an 
inflammatory condition of that organ. Long-continued functional 
lesion will eventually produce more or less organic disease; and 
you will find that in most cases of old dyspepsia there is more or 
less gastritis. But let us go farther, and inquire whether those 
views are borne out by the ordinary treatment of dyspeptic cases. 
When you open a book on the practice of physic, and turn to the 
article dyspepsia, one of the first things which strikes you is the 
vast number of cures for indigestion. The more incurable a disease 
is, and the less we know of its treatment, the more numerous is 
the list of remedies, and the more empirical is its treatment. Now 
the circumstance of having a great variety of " cures'' 1 for a disease, 
is a strong proof, either that there is no real remedy for it, or that 
its nature is very little understood. A patient afflicted with dys- 
pepsia will generally run through a variety of treatment, he will 
be ordered bark by one practitioner, mercury by another, purga- 
tives by a third ; in fact, he will be subjected to every form of treat- 
ment. Now all this is proof positive that the disease is not suffi- 
ciently understood. What does pathology teach in such cases? In 
almost every instance where patients have died with symptoms of 
dyspepsia, pathological anatomy proves the stomach to be in a state 
of demonstrable disease. It appears, therefore, that, whether we 
look to the uncertainty and vacillations of treatment, or the results 
of anatomical examination, the case is still the same; and that, 
where dyspepsia has been of considerable duration, the chance is 
that there is more or less of organic disease, and that, if we pre- 
scribe for dyspepsia neglecting this, we are very likely to do mischief. 
I do not wish you to believe that every case of dyspepsia is a case 
of gastritis. This opinion has brought disgrace on the school of 
Broussais. His disciples went too far ; for whether the gastric 
derangement depended on nervous irritation, or anaemia, or disease 
of the liver, or mental emotion, they prescribed leeches and water 
diet, and thus very often brought on the disease they sought to 
cure. We may have functional disease, independent of structural 
lesion, in the stomach, as well as in any other organ ; it is no un- 
usual circumstance, and the practical physician meets with it every 
day. A great deal of confusion, however, arises from the similarity 



64 



STOKES'S THEORY AND PRACTICE. 



of the symptoms. I remember an accomplished friend of mine 
getting into disgrace with one of the members of a board of exa- 
miners on this subject. He was asked to tell the difference between 
the symptoms of chronic gastritis and dyspepsia, and in reply stated 
that he could not. For this he was nearly rejected ; but, I believe, 
on a candid review of the circumstances, you will agree with me, 
that he knew more of the matter than the learned professor. In 
ninety-nine cases out of a hundred of chronic gastritis there is no 
fever, scarcely any thirst, often no fixed local pain, and this leads 
persons away from any idea of the existence of an inflammatory 
condition of the stomach. What are the symptoms of a chronic 
gastritis? pain of occasional occurrence, flatulence, acidity, swell- 
ing of the stomach, fetid eructations, sensation of heat and w ? eight 
about the epigastrium, and perhaps vomiting. Well, these are also 
the symptoms of dyspepsia, whether it be accompanied by inflam- 
mation or not. How then, when called to a case of this kind, are 
you to determine the point 1 I must mention to you here, that it 
is often hard to do this with certainty. There are two circum- 
stances, however, which you should always bear in mind, as they 
will afford you considerable assistance in coming to a correct diag- 
nosis ; first, the length of time vihich the disease has lasted ; 
secondly, the result of the treatment which has been employed. 
You will find, that where the disease is a chronic gastritis, that it 
has been of some duration, that it has come on in an insidious 
manner, and that it has been exasperated by the ordinary treat- 
ment for dyspepsia. Many persons think, that if you give a patient 
medicine, without regulating his diet or issuing a prohibition against 
full meals, that you can cure him, and that, as he has no fever, and 
can go about his usual business, there is no necessity for antiphlogis- 
tic regimen. But as the disease goes on, he complains of pain in the 
stomach during the process of digestion, feels uneasy after dinner, 
there is an unpleasant degree of fulness about the epigastrium, he 
also experiences a variety of disagreeable symptoms, sometimes 
being annoyed with pain in the chest, sometimes he says he feels 
it in the region of the heart, and sometimes about the cartilages of 
the eighth and ninth ribs. These symptoms subside after the j 
process of digestion is completed, but during its continuance they 
harass the patient. Very often relief is obtained by vomiting, and , 
hence some persons are in the habit of throwing up their food 
for the purpose of relieving themselves, and consequently can have f 
no benefit by it.* In some cases digestion goes on until the food ; 
seems to reach a particular point, and then an acute feeling of pain 
is experienced. In these cases the gastritis is generally circum- 
scribed, and is likely to terminate in circumscribed ulceration. 
Various fluids are rejected from the stomach during the course of a 
gastritis ; sometimes acid, sometimes alkaline, sometimes insipid 

* [I have been told by a person who was in the habit of familiar intercourse 
with Lord Byron, in Italy, that this was a common practice of the noble poet. — B. j | 



PATHOLOGY AND TREATMENT OF GASTRITIS. 



65 



and sweet, sometimes bitter and bilious. There is generally a 
degree of fulness about the stomach, and the epigastrium is tender 
on pressure, but no decided tumour, either of the pylorus, liver or 
spleen, although the epigastrium presented that appearance of fulness 
and tension termed by the French " renitence" The bowels, too, 
are constipated, and this is a matter worthy of your attention, for it 
sometimes unfortunately happens that the practitioner, mistaking the 
gastritis for simple constipation, goes on prescribing purgative after 
purgative, until the patient gets incurable disease of the stomach. 
I know a case of a lady who gets one stool a week by taking eight 
drops of croton oil. Some years ago she was in the enjoyment of 
excellent health ; her bowels happened to get confined, and she 
was treated by a systematic practitioner with continued purgatives ; 
her bowels are now completely torpid, except when they are 
subjected to this unnatural stimulus. There are thousands of 
persons treated in this way, because practitioners look to conse- 
quences and not to causes. 

There is one remarkable difference between acute and chronic 
gastritis, which deserves your attentive consideration, as it exem- 
plifies a law applicable to all viscera under similar circumstances, 
and this is, that the sympathetic irritations are not so frequent or 
so distinct in chronic inflammation as in the acute form, and hence, 
in a case of chronic gastritis we almost never have fever, and the 
affections of the nervous respiratory or circulating systems are by 
-no means so well marked. I may even go on to actual disorgani- 
zation of the stomach, and yet the patient will not complain of any 
particular symptom during its whole progress, which you could 
set down as depending exclusively on the sympathetic irritation of 
gastritis. Some of these cases, called dyspeptic phthisis, by Dr. W. 
Philip, are most probably examples of the sympathetic irritation of 
the lungs from chronic gastritis. Another case, respecting which 
much error prevails, is what has been called hypochondriasis. 
Persons labouring under these affections are condemned to run the 
gauntlet of every mode of treatment ; sometimes (and fortunately for 
themselves) they are sent to travel, sometimes they are treated with 
musk and antispasmodics, then with the mineral acids, then with 
purgatives and mercurials, and lastly, with bark, nitrate of silver, 
and stimulants. They go about like spectres from one practitioner 
to another, trying remedy after remedy, alternately sanguine with 
hope or saddened by disappointment, until at last they die, and, 
to the astonishment of all the doctors, the only disease found, on 
dissection, is inflammation and thickening of the mucous surface of 
the stomach. A condition, which, under these circumstances, it 
was difficult to say whether it was the original disease, or produced 
by "fair trials" of a number of powerful agents. Hypochondriasis 
is not always gastritis ; but it is now found that, in many cases, it 
commences and terminates with disease in the upper portion of the 
digestive tube and the assisting viscera. This you must always 
bear in mind. 

7 



STOKES'S THEORY AND PRACTICE. 



Chronic gastritis terminates in various ways. Sometimes the 
inflammation is limited to a particular spot of the stomach, and 
here we frequently discover circumscribed ulcerations. In very 
bad cases these ulcers go on perforating the various coats of the 
stomach, until at last the contents of that organ escape into the 
serous cavity of the abdomen, and the patient rapidly sinks under 
a fatal peritonitis. It does not follow however, that, in all cases of 
perforation, the contents of the stomach get into the peritoneum, 
causing death. Very often adhesions are formed, and the base of 
the ulcer is the serous covering of some other portion of the diges- 
tive system, or a false passage may be formed into the colon. One 
of the most common terminations of a chronic gastritis is, that the 
inflammation extends to other viscera ; the patient gets disease of 
the liver, spleen, peritoneum, or lungs, and sinks under a compli- 
cation of disorders. It was somewhat in this way that Napoleon 
died. He laboured for a considerable lime under chronic disease 
of the stomach, which seems to have been overlooked by his medi- 
cal attendants, and this terminated in the extension of disease to 
various other organs. 



LECTURE VI. 

Treatment of chronic gastritis — Frequent excitement of the vascular system necessary 
to the performance of the functions of the stomach — Local bleeding — Regimen — 
Counter-irritation over the stomach — Treatment of Broussais — Use of vegetable 
tonics — Oxide of bismuth — Acetate of morphia. 

I shall begin to-day with the treatment of chronic gastritis, and 
I beg of you to bear in mind what I mentioned at my last lecture, 
that this disease, in its true and pathological meaning, is not suffi- 
ciently recognised. In general, it gets some wrong name or other ; 
and as many practitioners are in the habit of prescribing for names, 
it generally meets with wrong treatment. It is called everything 
but what it is, and its remedies are as numerous and as various as 
its appellations. By some, it is called dyspepsia, and is treated 
with bitters, astringents, and stimulants; by others, it is termed 
constipation, and treated with purgatives; the school of Abernethy 
look upon it as an affection of the liver, and prescribe blue pill and 
black draught ; others give it the name of hypochondriasis, and 
exhaust the whole catalogue of nervous and anti-dyspeptic medi- 
cines in attempting its removal ; in fact, it is called everything 
but what it is, and the result is an unsteady and mischievous 
empiricism. 

You will recollect a fact, to which I alluded in my last lecture, 
that the physiological condition of the stomach requires that it 
should be subject to frequent excitements of its vascular tissue,[and 
that this increased vascularity being the consequence of a natural 
process, digestion is, generally speaking, exempt from any kind of 
danger. If the brain or lungs were to experience an equal increase 



TREATMENT OF CHRONIC GASTRITIS. 67 



of vascularity, sensibility, and excitement, the consequence would 
be dangerous, or perhaps fatal, and we should have pulmonary 
and cerebral diseases produced. But though the stomach enjoys 
such a remarkable exemption from the liability to acute inflamma- 
tion, under circumstances of repeated vascular excitement, yet the 
slow, insidious, chronic gastritis, is an exceedingly common affec- 
tion. I feel convinced that many persons die of it, or of the exten- 
sive class of fatal diseases which it frequently induces. But I 
rejoice to say, that we have good reason to hope that the progres- 
sive amelioration of medical science will materially diminish the 
amount of human suffering from this cause. As physiological 
medicine advances, the number of those who die of unrecognised 
chronic visceral disease will be less and less, because diagnosis 
will become more extended and certain, and practice more simple 
and successful. - 

The first thing you should do, when called to treat a case of 
dyspepsia, is to ascertain whether it be a purely nervous disease, 
or a chronic gastritis. The majority of practitioners give them- 
selves no trouble about this matter, not recognising the fact, that of 
the number of dyspeptic persons who seek for medical advice, a 
considerable proportion are really labouring under a chronic gas- 
tritis, and forgetting, that, in consequence of long-continued func- 
tional injury, what was at first but a mere nervous derangement 
may afterwards become complicated with organic disease. You 
must also bear in mind, that the stomach is perhaps placed under 
more unfavourable circumstances for bringing about a cure than 
any other organ, because the life of the individual demands that 
the stomach, though in a state of inflammation, should still continue 
to perform its functions. In treating diseases of other organs, you 
will have the advantage of a comparative state of rest; but, in a 
case of the stomach, if you wish to preserve life, you cannot pro- 
hibit nutriment, and, consequently, you must run the risk of keep- 
ing up these periodic vascularities which its condition requires, 
which, though harmless in health, become a source of evil when 
the stomach is diseased. The obvious deduction from this is, that 
the cure of chronic gastritis depends as much upon regimen as 
upon medical treatment, and particularly where the symptoms 
have arisen from long-continued excitement, as in the case of 
persons who live highly. Here the treatment chiefly depends on 
regulating the diet, and if your patient has sense enough to live 
sparingly for a few weeks or months, you may be able to effect a 
cure without other treatment. The great error is, that most prac- 
titioners attempt to cure the disease by specifics, and when these 
fail, they then go to the symptomatic treatment, prescribing some- 
times for acidity, sometimes for nausea, sometimes for flatulence, 
sometimes for constipation, or " the liver," or debility. 

You should be careful in the examination of such cases, and 
should try to ascertain whether these symptoms may not depend 
upon inflammation of the stomach ; for as long as the patient is in 



68 



STOKES'S THEORY AND PRACTICE. 



this state, the less you have recourse to symptomatic or specific 
treatment the better. It is hard to mention one single medicine 
which, in this state, will not prove stimulant, and if the stomach be 
unfit for stimulants, it must be unfit for the generality of medicines. 
There are numbers of cases of persons labouring under chronic 
gastritis, which have been cured by strict regulation of diet, and 
by avoiding every article of food requiring strong digestive powers. 
We find that articles of diet vary very much in this respect; some 
are digested with ease, some with pain. We might express this 
otherwise, by saying, that some require very little excitement of 
the stomach, and others very great vascular excitement. Patients, 
in this irritable state of stomach, can scarcely bear any kind of 
ingesta ; and when you consider the great vascularity, thickening 
of the mucous membrane, and tendency to organic disease, you 
will be induced to think that everything entering the stomach I 
should be of the mildest kind, and not requiring any powerful deter- 
mination of blood to that organ.* 

If you continually prescribe for symptoms, neglecting or over- 
looking the real nature of the disease, giving arsenic to excite the 
system, and iron to remove anaemia, and bitter tonics to improve 
the appetite, and alkaline remedies for acidity, and carminatives to 
expel flatus, you will do no good ; you may chance to give relief 
to-day, and find your patient worse to-morrow ; and at last he will 
die, and you may be disgraced. On opening the stomach, after 
death, you are astonished to find extensive ulceration, or, perhaps, 
cancerous disease. Very often, in such cases, practitioners say 
that it is cancerous disease, and that no good can be done. But j 
the thing is to be able to know, when you are called to a case, i 
whether it is a case of mere nervous dyspepsia, or chronic inflam- ! 
mation of the stomach. Some of the best pathologists think that 
most, of the cancerous affections of the stomach are, in the begin- [ 
ning, only chronic inflammations of that organ. 

I believe we have not yet in this country adopted the plan of 

# [This course, so conformable with reason and experience, and so readily un- i 
derstood by the attentive inquirer, is, however, the most difficult to be carried out ! 
in practice. Our patients will take every kind of nauseating drug- without much [ 
grimace; they will consent to be blistered and cauterised and punished, after every ; 
medical fashion: but so soon as we wish to substitute a regulated and restricted 
diet for this polypharmacy, they all at once discover innumerable difficulties in } 
the way. We then become cruel, starving doctors; withoutgood bowelsof ourown, | 
it is believed, and of course without compassion for the bowels of others ! In fact, a 
doctor will be much more likely to preserve his reputation in a family, whilst bring- 
ing on chronic, perhaps incurable, gastritis, by the needless administration daily of 1 
arsenic, than whilst he is successfully attempting the cure of a case of this disease J 
by a very restricted diet. It will be found with this, after all, as with many I 
other prejudices of the people, that they are but the reflexion or echo of former I 
opinions and now exploded hypotheses of the profession. If physicians, generally, I 
would cease, indolently perhaps oftener than ignorantly, to administer to the 1 
whims of their dyspeptic patients, the latter seeing a general concert of opinion 
among medical men, would be less reluctant to follow out literally the advice of | 
their immediate professional advisers. — B.] 



TREATMENT OF CHRONIC GASTRITIS. 



69 



moderate application of leeches to the epigastrium in cases of 
chronic gastritis. I have seen, in many cases, great benefit result 
from the repeated application of a small number of leeches to the 
epigastrium, at intervals of two or three days. Here is a point 
which you will find very useful in practice. You will meet with 
cases which have lasted for a long time ; cases where there is 
strong evidence of organic disease, and which have resisted the 
ordinary dyspeptic treatment. You will be called frequently to 
treat these three different cases : — where the disease has been of 
long duration ; where there is distinct evidence of organic disease ; 
and where the disease has resisted the ordinary dyspeptic treat- 
ment. Here is a case of a patient labouring under what is called 
indigestion, and which has resisted the stimulant, and tonic, and 
purgative treatment. Here is one fact. In the next place, the 
disease is chronic, and the probability is that there is inflammation, 
and consequently that there is chronic gastritis. Now if, in such 
a case, you omit all medicine by the mouth, apply leeches to the 
epigastrium, keep the bowels open by injections, and regulate the 
diet, you will often do a vast deal of good. I have seen, under this 
treatment, the tongue clean, the pain and tenderness of the epigas- 
trium subside, the acidity, thirst, nausea, and flatulence, removed, 
the power of digestion restored, and all the symptoms for which 
alkalies, and acids, and tonics, and purgatives, were prescribed, 
vanish under treatment calculated to remove chronic inflammation 
of the stomach. 

What is next in importance to regulated regimen and local 
bleeding 1 A careful attention to the bowels, which in chronic gas- 
tritis, are generally constipated, and this has a tendency to keep 
up disease in the upper part of the digestive tube. Is this to be 
obviated by introducing purgative medicine into the stomach t 
No. If you introduce strong purgative medicine by the mouth, 
you will do a great deal of mischief. You must open the bowels 
by enemata, or, if you give medicine by the mouth, by the mildest 
laxatives in a state of great dilution. A little castor-oil, given 
every third or fourth day, or a little rhubarb, with some of the 
neutral salts, will answer in most cases.* The diet, too, can be 
managed, so as to have a gently laxative effect.f The use of 
injections is, however, what I principally rely on. I have seen 
many cases of gastritis cured by the total omission of all medicine 
by the mouth, by giving up every article of food which disagreed 
with the stomach, and by the use of warm water enemata. I have 
seen this treatment relieve and cure persons whose sufferings had 
lasted for years previous to its employment, and who had been 

* [Salts are often singularly unfriendly to the stomach of a dyspeptic. Rhu- 
barb and soap pill, or rhubarb and carbonated magnesia with a little cinnamon 
or ginger well mixed, are preferable. — B.] 

f [And for this purpose bran or rye bread, ryemusliand milk for breakfast and 
spinach for dinner, are among the best articles. Butter-milk in season, and 
melasses and water for occasional drink, will tend to the same end. — B.] 

7* 



70 



STOKES'S THEORY AND PRACTICE. 



considered by many practitioners to labour under organic disease 
of an incurable nature. It is important that you should bear this 
in mind. The old purgative and mercurial treatment of gastritis, 
I am happy to say, is rapidly declining ; and British practitioners 
are now convinced that they cannot cure every form of dyspepsia 
by the old mode of treatment. I do not deny that many diseases 
of the digestive tube may be benefited by the mild use of mercury 
and laxatives, but I think I have every reasonable and scientific 
practitioner with me in condemning the unscientific routine prac- 
tice, which was followed by those who took the writings of Aber- 
nethy and Hamilton for their guide. I do not say that, where 
cases of gastric inflammation, treated after the plan of Mr. Aber- 
nethy, have proved fatal, the medicines have destroyed life; I 
merely assert that the patients died of inflammation, over which 
these medicines had no control ; and the error lay in mistaking 
and overlooking the actual disease, as much as in its maltreatment. 
You will find some practitioners (they are becoming fewer in 
number every day), who seem to have but two ideas, the one a 
purgative, the other a pot full of faeces ; but the connecting link — 
the gastro-enteric mucous membrane — that vast expansion, so 
complicated, so delicate, so important, seems to be totally forgotten. 
Bui practitioners are now beginning to see that purgatives are not 
to be employed empirically ; that they should be administered in 
many cases with great caution, and with a due attention to the 
actual condition of the alimentary canal, and that they have been 
a source of great abuse in the medical practice of these countries. 

Next to leeching, and a proper regulation of the bowels, is the 
employment of gentle and long-continued counter-irritation over 
the stomach. This may be effected by the repeated application of 
small blisters, or by the use of tartar emetic ointment. I have 
been in the habit of impressing upon the class, that the tartar 
emetic ointment used in these countries is too strong, the conse- 
quence of which is an eruption of large pustules, which are exces- 
sively painful, and often accompanied with such disturbance of 
the constitution as amounts to symptomatic fever. In fact, tartar 
emetic ointment of the ordinary strength produces so much irrita- 
tion, that few patients will submit to it long. The form which I 
recommend you to employ is the following : — Take seven drachms 
of prepared lard, and, instead of a drachm of tartar emetic, which 
is the usual quantity, take half a drachm, directing, in your pre- 
scription (this a point of importance), that it be reduced to an 
impalpable powder ; and you may add to it what will increase its 
action, one drachm of mercurial ointment. This produces a crop 
of small pustules, which give but little pain and are easily borne ; 
and the counter-irritation may be kept up in this way for a con- 
siderable time, by stopping, for a few days, until the eruption fades 
away, and then renewing the friction. I have often seen the utility 
of this remedy exemplified in cases of chronic gastritis, where the 
symptoms of gastric irritation, which had subsided under the em- 



TREATMENT OF CHRONIC GASTRITIS. 



71 



ployment of friction with tartar emetic ointment, returned when 
it was left oft', and again vanished when it was resumed. The 
case of the celebrated anatomist, Beclard, furnishes a very remark- 
able proof of the value of a well-regulated diet and repeated 
counter-irritation in the treatment of this disease. While he was 
engaged in the ardent prosecution of his professional studies he got 
an affection of the stomach, which he considered to be a chronic 
gastritis, and immediately put himself under a strict regimen, 
using, at the same time, repeated counter-irritation. He kept up 
the counter-irritant plan for a considerable length of time, for he 
found that, when he discontinued it, the gastric symptoms had a 
tendency to return. In this way he got completely rid of the dis- 
ease. Several years afterwards he died of an attack of erysipelas ; 
and, on opening his stomach, the cicatrix of an old ulcer was 
discovered in the vicinity of the pylorus, which was exactly the 
spot to which he had referred his pain during the continuance of 
his gastric affection.* 

There is, perhaps, no science in which the motto, " medio tutissi- 
mus ibis," is of more extensive application than in medicine. Some 
physicians on the continent, particularly the disciples of Broussais, 
having repeatedly witnessed the advantages of strict regimen and 
local depletion in chronic gastritis, have pushed this practice too 
far. They seemed to forget that the system requires support and 
nutrition, which can be effected only through the agency of the 
stomach ; they saw the evils which result from the use of stimu- 
lating food in cases of chronic gastritis; and, looking to these alone, 
they ran into the opposite extreme, the consequence of which was, 
that they kept their patients so long upon low diet that they 
actually produced the very symptoms which they wished to 
remove. The patients became dyspeptic from real debility of the 
stomach and the whole frame. You remember a general law of 
pathology to which I have alluded on a former occasion, and 
which I shall again mention, as it illustrates this point, namely, 
that opposite states of the economy may be accompanied by the 
same symptoms. Thus we observe, that palpitation may depend 
on two different causes — on a sthenic or asthenic condition — on 
the presence of too much or too little blood in the heart. Now, it 
frequently happened that patients, labouring under chronic gas- 
tritis, and who had been treated for a long time after the strict plan 
adopted by the Broussaists, finding themselves not at all improved, 
went to other physicians who had different views, and were rapidly 
cured, by being put upon a full nutritious diet. In this way numer- 
ous cases, which water diet and depletion had only aggravated, 
were relieved, and the consequence was, that a mass of facts was 
brought forward and published, not long since, by a French author, 
against the antiphlogistic treatment of dyspepsia and chronic gas- 

* [For additional means of producing counter-irritation, see the lecture on 
chronic rheumatism. — B.] 



72 



STOKES'S THEORY AND PRACTICE. 



iritis. It must be stated, however, that the cases which he pub- 
lished were chiefly those in which the depleting system had been 
carried to excess, and that they cannot, therefore, be received as 
proofs of the value of a stimulating diet in the treatment of chronic 
inflammation of the stomach. Bear this in mind ; the sooner you 
can put your patient on a nutritious diet the better will it be for 
him. It would be absurd to keep a patient for many months, as the 
Broussaists have done, on slops and gum-water. It will be neces- 
sary for you to feel your way and improve the diet gradually. 
Commence by giving a small quantity of mild nutritious food ; if 
your patient bears it well, you can go on ; if the gastric symptoms 
return, you can easily stop. If a small portion of the milder species 
of food rests quietly on the stomach, you may increase it the next 
day, or the day after, and thus you proceed to more solid and 
nutritious aliment, until the tone of your patient's stomach regains 
the standard of health. Never lose sight of this fact, that you may 
have a case of dyspepsia depending on a chronic gastritis, in which, 
though you remove the inflammation by a strict antiphlogistic treat- 
ment, you may not by this remove the dyspepsia ; and if you con- 
tinue to leech, and blister, and starve your patient, after the inflam- 
matory state be removed, you will do great injury. Such a patient, 
failing into the hands of another practitioner who treated him on a 
different system, might be relieved, and his case quoted against 
you and your treatment, though this, at the commencement, was 
judicious and proper. 

With respect to internal remedies, the school of Broussais think 
that there is nothing required but cold water and gum. This is 
going too far. In a former lecture, I have drawn your attention to 
the fact, that in the treatment of acute inflammation there is a 
point where antiphlogistics should cease, and where tonics and 
stimulants are the most efficient means of cure. Of this fact, the 
disciples of Broussais appear to be ignorant, and they consequently 
declare against every remedy for chronic gastritis except leeches 
and cold water. Now is this right ? I think not. We find that, 
in all cases of gastric inflammation, a change in medication seems 
to be useful at some period of the disease, that is, a change from 
antiphlogistics to tonics and stimulants, and I believe that in cases 
of chronic gastritis these remedies may be used with very great 
advantage, having, of course, premised depletion and counter-irri- 
tants. I believe, too, that most of the remedies, which we see every 
day unsuccessfully employed, would have acted beneficially, if the 
preparatory treatment, which I have mentioned, had been adopted. 
Among the best remedies of this kind is the oxide of bismuth ; I 
have seen more benefit from the use of this than of any other 
medicine, after the treatment already alluded to. Generally speak- 
ing, the list of internal remedies for chronic gastritis is very small, 
but after the use of antiphlogistics, you may prescribe the vegetable 
tonics and oxide of bismuth with advantage. The most decidedly 
valuable remedy, however, in the after stage of a chronic gastritis, 



TREATMENT OF CHRONIC GASTRITIS. 



73 



is the acetate of morphia, which, I am convinced, has a very 
powerful effect in allaying chronic irritation of the stomach. Dr. 
Bardsley, of Manchester, in one of his published works, entitled 
" Hospital Facts and Observations," adduces many cases of gastric 
irritation which were completely relieved by the use of this remedy, 
and I am perfectly satisfied of the truth of his statements. It may 
be said that Dr. Bardsley's cases were only instances of dyspepsia. 
But as his cases were extremely numerous, some of them of long 
standing, and the symptoms very severe, the great probability is, 
that some of them at least must have been cases of chronic gas- 
tritis. I know very few books, the perusal of which I would more 
strongly recommend to you than Dr. Bardsley's accurate and 
instructive work. The great besetting sin of medical writers is, 
that their statements of successful practice are grounded on a very 
limited number of cases, or that, in publishing the result of their 
practical investigations, they only give their successful cases, and 
leave out those in which the treatment recommended has been 
found inefficacious. Yet this is a circumstance which should 
never be neglected. If a man declares that he has discovered a 
cure for gastritis, or dyspepsia, and brings forwards one hundred 
cases in which the remedy has done go<?d, the statement is still 
unsatisfactory and insufficient, because there may be one thousand 
cases in which it has totally failed. Unless he comes forward and 
gives both his successful and unsuccessful cases, of what value are 
his statements ? Dr. Bardsley, with the candour and good sense 
which always characterize the philosophic inquirer, gives the 
result of all his cases, forms them into tables, and then leaves his 
readers to judge for themselves. From an inspection of these 
tables, you will be convinced of the efficacy of acetate of morphia 
in the treatment of chronic gastritis. I have been in the habit of 
using it with the most gratifying results after leeching, regulating 
the diet, and paying proper attention to the state of the bowels. 
There are some forms of the disease in which it is more useful 
than others. The particular form, in which it proves most service- 
able, is where there is a copious secretion of acid from the stomach 
(that form in which all kinds of alkalies have been exhibited), 
where severe pain and constant acidity are the prominent symp- 
toms. Here I have seen the acetate of morphia act exceedingly 
well. You may begin with one-twelfth of a grain, made into a 
pill with crumb of bread, or conserve of roses, twice a day ; the 
next day you may order it to be taken three times, and you may 
go on in this way until you make the patient take from half a 
grain to a grain and a half in the twenty-four hours. I shall here 
mention the circumstances of a case, which I do not mean to bring 
forward as an instance of cure, but as an illustration of the extra- 
ordinary power which acetate of morphia possesses in relieving 
gastric irritation. A gentleman of strong mind and highly culti- 
vated intellectual powers, which he kept in constant exercise, got 
a severe chronic gastritis ; his appetite completely declined ; he 



74 



STOKES'S THEORY AND PRACTICE. 



had frequent vomiting of sour matter ; fetid eructations ; and such 
violent pain in the stomach, that he used, when the attack came 
on, to throw himself on the ground, and roll about in a state of 
indescribable agony. He applied to various practitioners, had 
several consultations on his case, and the opinion of the most 
eminent medical men was, that he had incurable cancerous disease 
of the stomach. These symptoms continued for several years, but 
for the last two or three years they were quite intolerable. He 
had repeated cold sweats, vomited everything he took, even cold 
water, was reduced to a skeleton, and led a life of complete torture. 
Under such circumstances he tried for the first time, by my advice, 
the acetate of morphia. He tried it first in doses of one-tenth of a 
grain three times a day, and experienced the most unexpected 
relief. On the third day all his bad symptoms were gone. He 
had no pain, no vomiting, no sw r eats; his spirits were raised to the 
highest state of exhilaration, and he thought himself perfectly 
cured. He went out in the greatest joy, visited all his friends, and 
told them that he had at last got rid of his tormenting malady. In 
the evening he joined a supper party, indulged very freely, and 
next morning had a violent hsematemesis, to which he had been 
for some time subject. * All his old symptoms again made their 
appearance. He again had recourse to the acetate of morphia, and 
again immediately experienced relief, but the vomiting of blood 
again returned, so that he discontinued the remedy. This gentle- 
man is now in the enjoyment of good health. He regulated his 
diet, left off all medicine by the mouth, used warm water injections, 
and thus recovered from his supposed cancer. 

I do not bring this case forward as an instance of the curative 
effect of acetate of morphia, but as an instance of its powerful 
effect in allaying gastric irritation. I could adduce other cases in 
proof of its value in the treatment of the after stage of chronic j 
gastritis, and particularly of that form in which pain and acidity 
are the prominent symptoms ; but I perceive my lime has nearly | 
expired. At my next lecture, I shall give some other particulars I 
connected with this subject, and then proceed to the consideration 
of diseases of the small intestine. 



LECTURE VII. 

Friction with croton oil — Attention to diet during convalescence — Organic disease of 
the stomach — Principles of treatment — Diet and attention to the bowels — Duodenitis 
— Inflammation of the jejunum — Ileitis, complication and nature of — Dothinenteri- 
tis — Ulceration of the mucous membrane — Symptoms and diagnosis of ileitis. 

In speaking of the employment of counter-irritation in cases of 
chronic gastritis, I forgot to mention the use of friction with croton 
oil, which has been found beneficial in many cases of chronic 
inflammation. It has been extensively used by many practitioners 



ORGANIC DISEASE OF THE STOMACH. 



75 



in the treatment of chronic affections of the joints, and in various 
forms of pulmonary disease; and I have employed it myself in 
some cases of chronic gastritis with benefit. 1 cannot say that the 
cases in which I have used it presented all the symptoms of chronic 
gastritis, but they were certainly cases of chronic gastrodynia, with 
severe local pain, nausea, and loss of appetite. It is an excellent 
counter-irritant, and gives very little pain. The mode in which I 
employ it is this — take a few drops of croton oil, five or six, for 
instance, drop them on the epigastrium, and rub them in with a 
piece of lint or bladder, interposed between your finger and the 
skin, and the next day you have an eruption of small papulas, 
which you can increase at will. There is one interesting circum- 
stance connected with the use of croton oil frictions, which you 
should be made acquainted with. The liability to produce counter- 
irritation, seems to depend upon the absorption or non-absorption 
of the croton oil; if it be absorbed it will purge, but if it be not it 
will produce counter-irritation. In cases of this kind, therefore, 
where it produces the necessary degree of irritation in the skin, the 
chances are, that it will not act disagreeably by bringing on ca- 
tharsis. I have only seen one case where there were both the 
eruption and catharsis. This was a gentleman who had lately 
suffered from dysentery in warm climates. 

I may also mention, that, in convalescence from an attack of 
chronic gastritis, you must pay great attention to diet for a long 
time, because there is no affection of any organ in the body, in 
which an error in diet so rapidly induces a return of the original 
symptoms, as in diseases of the stomach, while each return of the 
disease renders the attack more dangerous and unmanageable, 
until at last disorganization takes place.* 

* [Aware of the continued influence which the brain exerts over the stomach, 
in quickening 1 , retarding, or perverting- its functions, according- as the mind is 
pleasurably exercised or the reverse, the practitioner cannot be long- regardless of 
the necessity of recommending to his dyspeptic patient a change of scene, and 
a substitution of amusements for the strain upon his attention of business with its 
cares and anxieties. For this purpose, traveling is preferable to the methodical 
exercise and stated recreations which may be taken at home. Indeed, it is often 
impossible to induce a person of regular business habits, or even the idle hypo- 
chondriac, to go through any regular training, by walking, and riding, and gym- 
nastic exercises at home. The theatre of his movements must be entirely 
changed. If, whilst this is done, he is, also, in quest of some particular object, — 
such as mineral springs, new and beautiful scenery, the splendour of modern, 
and the tasteful remains of ancient art, — so much the better. Change of scene 
and travel, are beneficial in another way, besides acting on the nervous system. 
The stomach always gains by the inhalation of pure air in the lungs, and the sub- 
sequently more complete process of respiration, as it invariably suffers in a close 
and impure air. 

In addition to the revulsive agents on the skin mentioned in the text, are the 
tepid and occasionally the warm bath, and assiduous friction and shampooing ; 
from all of which the dyspeptic patient derives great relief and comfort. If to 
these we add active and somewhat varied exercise, short of producing fatigue, the 
revulsive plan of treatment of chronic gastritis will be complete, and we shall 
then accomplish all that can be desired in the interests of humanity and philo- 



76 



STOKES'S THEORY AND PRACTICE. 



This leads me to speak of organic disease of the stomach. On 
this subject I shall be very brief; the best mode of communicating 
information will be to exhibit these preparations ; you will derive 
more instruction from their inspection than from any lecture I 
could deliver. (Dr. Stokes here exhibited a number of beautiful 
preparations from the Park street museum, illustrative of various 
organic lesions of the stomach.) Here is a case, which some pa- 
thologists would call cancer, others chronic gastritis. I may 
remark here, that pathologists are divided as to what is the cause 
of cancer of the stomach, but the best informed are of opinion that, 
in those cases of gastric disorganization which are called cancer 
or scirrhus, all that can be demonstrated by the knife is referable 
to the results of chronic inflammation. This is a different propo- 
sition from saying that chronic inflammation alone will produce 
cancer. As yet we know little of cancer ; dissection of cancerous 
organs gives but scanty information; but this seems certain that, 
in particular conditions, of the economy, an inflammation of the 
stomach will end in cancerous disease. Here is an excellent pre- 
paration of the stomach of a person who died of cancer of that 
organ. For several years before his death he had a jaundiced 
look, an emaciated appearance, frequent vomiting, and severe pain 
towards the termination of the digestive process, a circumstance 
which denotes disease of the pylorus. He also had hsematemesis. 
You see the inner surface in the vicinity of the pylorus presents 
ulcerations of the mucous membrane and thickening of the sub- 
mucous cellular tissue. The pylorus itself does not appear to be 
at all contracted, but the parts around it are in a state of extraordi- 
nary disease. Look at the preparation again, and say what could 
bitters, or acids, or alkalies, or tonics, have effected in a case of 
such extensive disease. Here is a stomach in a state of long con- 
tinued chronic inflammation, and exhibiting lesions, which some 
would designate as cancer of that organ. Now, though I do not 
know the treatment which this patient underwent, I would venture I 
to say that he took plenty of the usual anti-dyspeptic medicines. 
Yet, in a vast number of cases, where enormous quantities of these I 
remedies are taken daily, the stomach is in as bad a state as that 
preparation exhibits, and I feel the more strongly convinced of this, 
because I am aware that many persons die after having gone 
through the whole routine of anti-dyspeptic practice, and, when j 
they are opened after death, incurable disease of the stomach is 
discovered. Here is an example of vast cancerous disease of the 
stomach; here is a very interesting specimen of chronic gastritis, 
chiefly representing a most remarkable and circumscribed ulcer at 
the termination of the stomach. Here you see is the ulcer, with 
raised, thickened, and introverted edges. Now, in all probability, • 

sophical medicine, by saving- the stomach from drugs, and yet curing" the phlogo- 
sis which disordered this organ in the first place, and of the languor and deficient 
secretory action in which it participated with the rest of the system in the ' 
second. — B.] 



I 



ORGANIC DISEASE OF THE STOMACH. 



77 



this ulceration was exceedingly chronic, for you perceive nature 
has been at work with it, and has made some attempts at repara- 
tion. It is in such a case as this that patients generally refer their 
pain to a particular part of the stomach : digestion goes on without 
any pain until the food reaches a certain point, when acute pain is 
felt, and this continues until it is relieved by vomiting. The 
occurrence of this symptom, after an attack of acute gastritis, would 
lead you to suspect the formation of one or more ulcers, and the 
persistence of this localized pain should induce you to persevere in 
employing every means in your power calculated to remove the 
disease. The preparation which I now exhibit is interesting, as it 
shows the effect of corrosive poison on the stomach. The patient, to 
whom this stomach belonged, died in consequence of swallowing 
a quantity of sulphuric acid ; here you see the consequences — the 
mucous membrane is black and disorganized, exhibiting this rag- 
ged appearance. In some cases of malignant fever we have found 
the stomach presenting somewhat similar appearances ; and the 
same state of the stomach is described by some writers as occur- 
ring in cases of intertropical fever. Here is a preparation which 
you should inspect; chronic gastritis with a large ulcerated patch 
in the centre of the stomach. Here is another example of extensive 
cancerous disease. 

A very few words will suffice for the state of the science on the 
subject of cancer of the stomach. It is very hard, nay, even almost 
impossible, to draw a line of distinction between the symptoms of 
cancer of the stomach and chronic gastritis, and I believe it is ad- 
mitted on all hands that the same causes give rise to both. Long 
continued irritation will, in one case, produce cancer of the sto- 
mach, in another, chronic gastritis. Again, it is admitted by many, 
that what is called cancerous ulceration of the stomach has no 
appreciable difference from ulceration in various other organs ; and 
hence some other persons have gone so far as to say that there is 
no such thing as cancer of the stomach (separately considered) ; 
and that all the cases adduced of it are nothing more than so many 
forms of chronic gastritis. In the present state of medicine, we 
are not, indeed, possessed of any data which would enable us to 
come to a final determination on thi squestion. It is certainly im- 
possible to determine this point ; but if there be anything peculiar 
in cancerous matter, similar to tubercular or melanotic matter, 
there is no reason why, under the influence of inflammation, it 
should not be developed in the stomach as well as in any other 
part of the body. But whatever views we entertain on this subject, 
we must confess that, in the majority of cases, there is a chronic 
gastritis, and that the principles of treatment which would alleviate 
the patient's sufferings and prolong life, are those which are calcu- 
lated to prevent the occurrence of gastric inflammation. The more 
you approximate the treatment of cancer to that of chronic gastritis, 
the greater comfort will you afford your patient, and the more will 
you prolong his existence. 



78 



STOKES'S THEORY AND PRACTICE. 



The most celebrated case on record of this affection is that of the 
Emperor Napoleon. He died with extensive ulceration of the sto- 
mach, which, of course, was called " cancerous" and there were 
also distinct traces of disease in the liver, the mucous coat of the 
intestines, and the lungs. His disease was believed by himself to 
have originated in the stomach, and to this opinion he adhered, 
notwithstanding the results of some solemn consultations, at one of 
which his affection was declared to be an " obstruction of the liver" 
with a " scorbutic dyscrasy" At another it was pronounced to 
be a " chronic hepatitis" and a course of mercury recommended ! 
When we reflect on this, and read in the account by Gaubert, 
(which you will see in the Examen des Doctrines Medicates]) the 
regimen which was used, and the list of stimulating medicaments 
employed, you will not wonder at the words of this great man, 
when he was pressed to take more drugs, to swallow the universal 
nostrum, mercury, to which he had the greatest aversion. " Your 
disgusting preparations are good for nothing. Medicine is a 
collection of blind prescriptions, which destroy the poor, sometimes 
succeed with the rich, but whose whole results are more injurious 
than useful to humanity." But he got mercury, notwithstanding, 
mercury for his " digestive organs;" to " excite the liver;" to "re- 
move its obstruction," and mercury to create bile, and purgatives 
to remove it; and tonics, and antacids, and stimulants; and he 
died in torture, and his body was opened, and the stomach was 
found " cancerous" 

I should not omit mentioning to you, that in those cases of 
chronic gastritis which run on to an incurable stage, the best 
treatment consists in a careful regulation of diet, in keeping the 
bowels open by enemata, or the very mildest laxatives, and in 
avoiding everything capable of producing excitement. You will 
also derive advantage from the employment of gentle counter- 
irritation, and from the internal use of narcotics, which in such 
cases appear to have a more beneficial effect than any other class 
of remedies. With the exception of these, I do not know any 
other kind of medicine you can safely employ? and I believe that, 
in the majority of cases, you will find that the patients have taken 
already too much medicine. Anxious for relief, and urged on by 
the hope of obtaining some remedy capable of relieving their suf- 
ferings, they have recourse to every grade of quacks, are persuaded 
to swallow every kind of drug, and are subjected to every form of 
harassing and mischievous treatment. The diet which you pre- 
scribe for such patients should be sparing but nutritive ; give the 
stomach as little to do as will be consistent with the support of life 
and strength ; and you may take it is a general rule in the treat- 
ment of all chronic affections of the digestive tube, whether cancer 
of the stomach, scirrhus of the pylorus, or stricture of the intestines, 
that there are two great principles of general application — preserv- 
ing a gently open state of the bowels, and allaying inflammatory 
excitement. 



DISEASES OF THE SMALL INTESTINES. 79 



Duodenitis. — Let us now proceed to the remaining parts of the 
digestive tube, of which the next in order is the duodenum. I shall 
not dwell much to-day on the subject of duodenitis; as I shall 
revert to its consideration when speaking of jaundice, because 
inflammation of the duodenum is a common cause of jaundice, 
perhaps the most common, if we take the whole of its cases to- 
gether. You are not to suppose that I wish to inculcate the 
doctrine that jaundice is a necessary complication in duodenitis, 
but it has been proved that there is an extraordinarily frequent 
coincidence between both, and that jaundice very often seems in- 
dependent of any mechanical cause, such as an obstruction of the 
biliary ducts. So far from this, that, in some cases, particularly 
those which are produced by, or accompany, a duodenitis, we have 
intense universal jaundice at the same time that the bile is flowing 
freely into the digestive tube. 

The researches of the immortal Bichat gave the first hint which 
directed the attention of practitioners to the circumstance, that, in 
many cases where jaundice had existed during life, there was no 
obstruction or disease in the liver of biliary ducts, but that in such 
cases there was always more or less inflammation in the part of 
the digestive tube into which the bile was immediately discharged, 
and this led ultimately to the discovery of the connection which 
exists between inflammation of the duodenum and jaundice. In 
treating of the sympathies which depend upon continuity of sur- 
face, Bichat refers to the connection which exists between the 
surfaces of mucous membranes and the ducts which open on them, 
and endeavours to show that the natural mode of excitement in 
all secreting glands is a stimulus applied to the surface on which 
their ducts open. As examples of this, he instances the effect 
which food and other substances, applied to the mucous membrane 
of the mouth, have in stimulating the salivary glands; the effect 
which stimulants applied to the conjunctiva, or nose, have on the 
lachrymal gland, and many others. Hence Broussais concludes 
that, when the mucous surface of the duodenum is thrown into a 
state of excitement, we may have a consequent affection of the 
liver, for the duodenum bears the same relation to the liver as the 
mouth does to the parotid glands. That this is frequently the case, 
I think, is very probable. It is now established, that the cause of 
the yellowness in what has been called yellow fever, is disease of 
the upper part of the digestive tube, in which the duodenum is 
always involved; and that the fever itself (the typhus icterodes of 
the nosologists) has been found to be greatly connected with in- 
flammation of the stomach and duodenum. During the epidemic 
] of 1827, we had in the Meath Hospital a great many cases which 
| bore a striking resemblance to the yellow fever of warm countries, 
I and particularly in this, that they were accompanied by intense 
| jaundice, and inflammation of the upper part of the digestive tube. 

You will see in the works of Rush and Lawrence, two of the best 
J American writers on yellow fever, that, of the numerous bodies 



i 

! 



80 



STOKES'S THEORY AND PRACTICE. 



they examined, there were scarcely any in which the jaundice 
was found in connection with liver disease, but that in all cases 
there w r as intense inflammation of the digestive surface. I shall 
return to this subject when I come to speak of liver disease. 

With respect to the jejunum, I may state that we know very 
little of the symptoms which characterize inflammation of this 
part of the intestinal canal ; and it is a curious pathological fact, 
that this portion of the tube is, of all others, the least liable to in- 
flammation. 

In point of fact, we have no means of ascertaining what are the 
prominent symptoms of inflammation of the jejunum, because, in 
almost every case in which jejunitis has been discovered, there has 
been also extensive disease of the rest of the small intestine. . We 
have cases of simple gastritis; there have been also cases of dis- 
tinct disease of the duodenum. We may have disease in the lower 
third of the ileum, unaccompanied by an affection of any other 
part of the tube. The same thing may occur in the case of the 
caecum, colon, or rectum, but it seldom or never occurs so far as 
the jejunum is concerned. I shall therefore pass over jejunitis, and 
proceed to draw your attention to one of the most important dis- 
eases to which the human subject is liable — inflammation of the 
ileum. 

Ileitis. — Inflammation of the ileum is a most important affection, 
for two reasons ; first, in consequence of its extraordinary frequency, 
and, in the next place, of its insidious latency, the disease gener- 
ally requiring a considerable degree of tact and experience on the 
part of the practitioner to make out its diagnosis with certainty. 
In fever, it is the most frequent of all forms of intestinal inflamma- 
tion : and hence Broussais, finding inflammation of the ileum of such 
constant occurrence in fever, concluded that fever was only symp- 
tomatic of intestinal inflammation. Further researches have shown 
that he was mistaken, and that the inflammation of the digestive 
tube is, in many cases, secondary ; but it is still a circumstance of 
almost constant occurrence, and in many cases of fever is the cause 
of death. Now, the portions of the intestinal tube most commonly 
affected in fever are the stomach and lower part of the ileum ; 
and the frequent occurrence of this in fever is very remarkable. 
There are few cases of typhus without it. In some cases of typhus 
you will, on examination after death, be astonished to find exten- 
sive disease of the intestinal canal, which, during life, had not 
attracted any particular notice, and this you will most commonly 
find in the lower part of the ileum. So common is it, that Louis 
says that ileitis is the grand anatomical feature of typhus fever; 
that is, had he been obliged to pitch on the lesion of some particu- 
lar organ as giving a character to typhus, he would say that it was 
ileitis. There are other diseases, too, in which inflammation of 
the ileum forms the principal complication. In the diseases of 
children, which go by the names of worm fever, remittent fever, 



DISEASES OF THE SMALL INTESTINES. 



81 



and bilious fever, I believe that ileitis is generally the first affection, 
and that the fevers are only symptomatic of it. It constantly 
occurs at some period or other of tabes mesenterica ; and I believe 
that in many cases it precedes the affection of the mesenteric 
glands. • It is exceedingly common in phthisis. In every case of 
phthisis, where diarrhoea has lasted for some time, the probability 
is, that there is ulceration in the cascum, colon, and lower part of 
the ileum. 

Now, what is the nature of this ileitis? This preparation, {hand- 
ing one for inspection,) which I beg of you to hand round, will 
furnish a very good illustration of the disease. Here is a portion 
of the intestine exhibiting various distinct ulcerations of different 
sizes, occupying the situation of the mucous glands. I do not mean 
to say that the character of the disease consists in this distinct 
ulceration ; it is an essential disease of the mucous membrane, and 
of its glands, which exist in great numbers on the surface of the 
lower third of the ileum, and are called solitary, and aggregate. 
These glands frequently take on the inflammatory condition, be- 
come softened, run into ulceration, and produce extraordinary 
sympathetic irritation of the whole system. There has been lately 
a great deal of discussion with respect to the question — Whether 
disease begins in the glands or in the mucous membrane-,, and 
whether we can separate disease of the glands from, disease of the 
mucous membrane. This has been carried to a great extent; and 
a change has been attempted to be made in the name of the disease, 
it being entitled dothinenteritis by those who say that the inflam- 
mation commences in the glands. But this I think is a mere 
refinement, and is carrying the thing too far. It is next to impos- 
sible for the glands to be affected without involving the mucous 
membrane, or for the mucous membrane to be affected without an 
extension of the disease to the glands. We sometimes, however, 
see the mucous membrane diseased without the glands being 
apparently engaged,; but I think the glands are never engaged 
without the co-existence of disease in the mucous membrane. In 
this preparation you see the mucous membrane is just giving way ; 
and here is an actual slough, where the mucous and submucous 
tunics have yielded to the inflammation. In the lower portion of 
the ileum we meet with an infinite variety in. the size and number 
of the ulcerations : in some they are very close and numerous, in 
others there are only two or three detached ones ; in some, the 
whole circle of the intestine is destroyed ; and the ulcer is- nearly 
as broad as the palm of your hand. It is interesting to consider, 
with respect to the pathology of the respiratory and digestive sys- 
tems, how it comes that ulceration of the mucous membrane is so 
much more common in the digestive apparatus than in the respira- 
tory. For one ulceration of the bronchial mucous membrane 
from acute disease, you will have one hundred of the gastrointes- 
tinal. For this peculiarity we cannot clearly account ; but there 
seems to be more development in the digestive than in the respira- 

8* 



82 



STOKES'S THEORY AND PRACTICE. 



tory system, and that this over-development produces a tendency 
to diseases. This, perhaps, is an approximation to an explanation 
of the facts; and to this may be added, that the mucous mem- 
brane of the intestines is exposed to the influence of a much 
greater variety of agents. It is difficult to give an accurate idea 
of the symptoms of ileitis, as we can only arrive at a knowledge 
of it by negative evidence, or, as the French term it, "par voie 
d' exclusion." 

In a case of gastritis and of inflammation in the upper part of 
the digestive tube, the most prominent symptoms are thirst and 
vomiting. In this affection, too, there is thirst, but it is by no 
means so urgent as in the former cases, and there is generally no 
vomiting. In a case of acute gastritis there is always a desire for 
cold drinks. In this disease there is also a desire for fluids, but 
the patient prefers them warm. Here you perceive two symp- 
toms connected with the predominance of disease in the upper part 
of the digestive tube are absent — vomiting and the desire for cold 
drinks. 

Now, you are aware that, in a case of inflammation of the 
colon and rectum, the most prominent symptoms are diarrhoea, 
tenesmus, and the passing of a quantity of morbid secretions. 
These symptoms, in a case of ileitis, are either wanting, or they 
are so slight as to excite very little notice. If, then, in a case of 
intestinal disease, we abstract the characteristic symptoms of disease 
in the upper and lower part of the digestive tube from the pheno- 
mena of the existing disease ; if we find that it presents symptoms 
which do not properly belong to either the stomach, duodenum, 
colon, or rectum ; we conclude that it must depend on a lesion of 
the remaining part of the canal, and we are in this way led to the 
diagnosis of ileitis. Let us enumerate the symptoms of an ileitis. 
In the first place, thirst, without a preference for cold drinks ; in 
the next, absence of vomiting; again, in the early period of the 
disease there is generally a tympanitic state of the belly, and the 
patient seldom complains of pain, even in fatal cases. This is a 
point of extreme importance. There is, however, most commonly 
a degree of tenderness over the ileum, which you will be able to 
detect by an accurate examination, and this tenderness presents a 
remarkable difference from the tenderness of gastritis, both in de- 
gree and situation. It is very seldom so exquisite as in a case of 
gastritis, the patient can bear a considerable degree of pressure, 
and the tenderness, in place of being towards the epigastrium, is 
situated between the umbilicus and the crest of the ileum on the 
right side; here pressure excites pain. The tongue in this affec- 
tion is generally of a dirty white, pointed, and red along the edges 
and tip ; the pulse is quick and small, and the face is contracted. 
As to the nature of the discharges from the bowels they are ex- 
ceedingly various ; there has been as yet no diagnosis founded on 
their appearance, and in some fatal cases they have been observed 
to retain an almost perfectly healthy appearance throughout. 
What would the gentlemen who draw their diagnosis from the 



PATHOLOGY OF ILEITIS. 



83 



chamber-pots say in such cases? I have seen perfectly natural 
stools in cases which immediately after have terminated fatally, 
and where, on examination after death, there was a vast extent of 
ulceration in the ileum. In addition to the symptoms just recited, 
the patient most commonly has/ever, and this presents itself under 
various forms, frequently assuming the type of a simple continued 
fever ; hence, in a great many cases, the patient is merely sup- 
posed to labour under simple continued fever, and the existence of 
extensive inflammation of the ileum is entirely overlooked. In 
other instances, there is more or less prostration, which increases 
with the progress of the disease, and the fever frequently receives 
the appellation of typhoid. Under these circumstances, the patient 
often gets bark and wine, every means is taken to support his 
strength and remove the typhoid condition of the system, the 
inflammation of the intestine is exasperated by neglect and mal- 
treatment, the patient dies 5 and, on dissection, the ileum presents 
an enormous sheet of ulcerations. 

In cases of this kind, where the diagnosis depends as much on 
negative as on positive circumstances, it is of importance to have 
a direct sign by which we may be able to ascertain, with some 
degree of certainty, the existence of a suspected enteric inflamma- 
tion, and I think I have discovered one, which I believe has not 
been as yet noticed ; this is increased pulsation of the abdominal 
vessels. In many cases of acute inflammation of the brain, the 
increased pulsation of the carotids has been frequently remarked, 
and every one sees, that, under such circumstances, there is an 
undue excitement of these vessels, or, in other words, that there is 
a want of proportion between the action of the carotids and that 
of the arteries of the extremities. If your finger be attacked by 
paronychia the same phenomenon is observed, the artery leading to 
the inflamed finger beats much stronger than the artery of the 
corresponding one on the opposite side. From these circumstances 
I was led to conclude, that, in cases of acute inflammation of the 
digestive tube, there would be increased pulsation of the abdominal 
aorta ; and on following up the investigation by examining several 
persons who had distinct and well marked intestinal inflammation, 
I found that my conclusions were well-grounded. In such cases, 
I found not only a remarkable throbbing of the abdominal aorta, 
but I also discovered that this throbbing was prolonged to the fe- 
moral arteries, and that, on the other hand, there was little or no 
corresponding excitement in the arteries of the upper extremities. 



LECTURE VIII. 

Diseases of the small intestines — Symptoms of ileitis — Occurrence of diarrhoea with 
fever symptomatic of this form of inflammation — Frequency and symptoms of the 
disease in children — Tabes mesenterica, treatment of. 

At my last lecture I was engaged in the consideration of disease 
of the small intestines : let us now resume the subject. You re- 



84 STOKES'S THEORY AND PRACTICE. 

member I mentioned to you that most of our knowledge of the 
inflammatory affections of the small intestines refers to the ileum, 
and that, in point of fact, we know little or nothing of disease of 
the jejunum. This, however, is not of much importance, of all 
the parts of the digestive tube, the jejunum is the least liable to 
disease, and is seldom or never engaged without the co-existence 
of disease in the ileum or duodenum. You recollect I drew your 
attention strongly to the extreme frequency of inflammation in the 
lower third of the ileum, and the importance which it derives from 
this as well as from its insidious latency. I showed that it was 
one of the most common secondary lesions in typhus fever, and a 
frequent cause of death. This cannot be impressed too much upon 
your minds — it is a point of pathology on which the best informed 
medical men are agreed. It may also, and very often does, occur 
as a pure idiopathic affection, without being preceded or superin- 
duced by that morbid state of the whole economy to which we 
give the name of fever. I said it was extremely common in chil- 
dren ; that here it was in many instances mistaken for worms, or 
bilious, or remittent fever ; that it constantly occurred during the 
progress of tabes mesenterica, and often appeared to have the 
initiative. I alluded to the discussion which has arisen as to the 
question whether disease begins in the glands or mucous mem- 
brane, and stated that such discussions are useless, as it is impos- 
sible to separate the two affections in diagnosis or treatment, and 
practical medicine gains nothing by the distinction. 

With respect to the sy mptoms of ileitis, I observed that they were 
those of a general affection of the digestive tube, the phenomena 
which indicate irritation, at its upper and lower part being absent. 
That if you abstract from symptoms of a general affection of the 
intestinal canal, the vomiting and desire for cold drinks which 
characterize inflammation of the upper part, and the diarrhcea and 
tenesmus which denote disease of the lower part, you will have the 
diagnostic marks of an ileitis. At our last meeting I showed you 
some preparations illustrative of this disease; I intended to have exhi- 
bited others of the same kind to-day, but regret that I cannot lay my 
hands on them at present. Allow me to rehearse the symptoms 
of ileitis once more. Thirst, without desire for cold drinks ; absence 
of vomiting, and of the characteristic symptoms of inflammation 
of the colon and rectum ; early tympanitis, generally on the second j 
day of the disease ; absence of pain, but existence of tenderness on 
pressure between the umbilicus and the crest of the ileum ; pointed 
tongue, of a dirty white on the upper surface, and red at the sides j 
and tip; contracted features; quick, small pulse; fever, and, what 
I forgot to mention in my last lecture, scanty high-coloured urine, 
a very constant symptom, so much so that I have known this dis- 
ease mistaken for an affection of the kidney, and the patient treated 
accordingly. I must add, that the patient died, that the kidney 
was found perfectly healthy, the ileum in a state of violent inflam- 
mation, and the suppression of urine to be referred to this cause 
alone. 



PATHOLOGY OF ILEITIS. 



85 



I drew your attention at my last lecture to the increased pulsa- 
tion of the abdominal aorta and its immediate branches, and stated 
that I looked upon this as a direct sign of abdominal inflammation. 
I do not mean to say that every case of increased action of the 
great abdominal arteries is significant of ileitis or intestinal inflam- 
mation. We see unusual pulsation of the abdominal aorta in 
hysterical females, and see it subside under the use of antispas- 
modics ; we see it in painter's colic ; we see it in cases of extreme 
emaciation; we see it in disease of the aorta, or some of its first 
large branches. What I wish to draw your attention to is this : 
where we have this symptom in addition to other signs of inflam- 
mation of the digestive tube, it is of considerable value as a diag- 
nostic. 

You may remember I stated that ileitis, from being generally 
attended by fever of the continued type, has been frequently supposed 
to be simple -continued fever, and that this was one of the conse- 
quences which resulted from the latency of the disease. Petit was 
the first who described this disease rightly. He described it under 
the name of entero-mesenteric fever, that is to say, fever depending 
on disease of the mesenteric glands and small intestine. The fol- 
lowing is an outline of his description: " The attack comes on with 
debility, irregular fever, quick, small pulse, sunken countenance, 
perhaps some diarrhoea, a lustrous expression of the eye." I may 
remark here that the occurrence of diarrhoea without any evident 
affection of the great intestine, and accompanied by fever, is almost 
always a sign of ileitis. It too often happens that practitioners, as 
I before remarked, prescribe for names. In cases of pulmonary 
disease, if the patient has fever, with copious expectoration, they 
say he is labouring under an attack of bronchitis ; but in case of 
intestinal inflammation, accompanied by increased secretion, it is 
different; they merely say he has diarrhoea, and prescribe for it 
without connecting it with its proper cause. The general rule is, 
that when you have diarrhoea with fever, there is inflammation of 
the digestive tube. 

In inflammation of the ileum the patient generally lies on his 
back, and avoids motion as much as he possibly can, his skin is 
dry and harsh; he is feverish; he has thirst, but little desire for 
cold drinks ; he scarcely ever vomits; his alvine dejections are 
sometimes thin and purgative, sometimes figured and natural. 
But there is one circumstance which is of considerable importance 
in pointing out the amount of disease, even in cases where patients 
have considerable diarrhoea, and this is, that the diarrhoea is not 
sufficient to account for the extraordinary prostration. There must 
be some cause for the great reduction of vital power besides the 
mere diarrhoea, and I must state to you that there are few diseases 
which bring on such rapid prostration as inflammation of this por- 
tion of the digestive tube. In the advanced stage of this disease 
the patients have cold skin, subsultus tendinum, petechia?, involun- 
tary discharge of urine and fasces, low delirium, coma, gangrenous 



86 



STOKES'S THEORY AND PRACTICE. 



ulcerations of the back, sinking of the powers of life, effusions into 
the head and chest, in fact all the symptoms which characterize 
the last stage of typhus. Generally speaking, the disease is more 
or less prolonged, and the patients die of exhaustion, but in some 
cases the approach of death is more sudden and formidable. Some 
of the ulcers pass deeply into the substance of the intestine, perfo- 
rate all its coats in succession, the contents of the intestine escape 
into the peritoneum, and the patient is carried off by a rapid 
peritonitis. 

Inflammation of the ileum is very frequently met with in chil- 
dren, and it is most important that you should be aware of the ex- 
treme frequency, as well as the symptoms, of this disease, in those 
little creatures. There is one fact in pathology which seems not 
to be generally acted on — that there is a class of diseases which 
are intra-uterine, and with which a child may be born. There are 
a great many cases of this kind on record, but still, I must confess, 
there is a great scope for investigation, and that our knowledge 
on this subject is imperfect. I believe that any one who has the 
opportunity of dissecting a great number of still-born children, or 
of those who die immediately after birth, would, by examining the 
state of the different cavities, and publishing the results of his 
examinations, earn for himself very great reputation. It is a well 
known fact that children may be born with hydrocephalus, with 
tubercles in the lungs, with acute inflammation of the stomach ; 
nay, more, children have been known to be born with chronic gas- 
tritis, and with old ulcerations in the ileum and colon. When 
children happen to be born with gastro-enteric disease, they are 
puny and weak ; the fact of this occurrence is generally overlooked, 
the case is considered to be one of general debility, and hence most 
of those children are lost in consequence of their medical attendants 
being ignorant of the real nature of the disease. It is a very 
curious fact, too, that where enteric disease occurs in very young 
children, it is frequently met with without any accompanying fever, 
and this is a point of great importance. Here is a fact not gene- 
rally known. A new-born infant has vomiting, swelled belly, con- 
tracted features, but at the same time he has cold skin and feeble 
pulse ; he has no distinct symptoms of fever, and a puny and feeble 
state of constitution appears to be the prominent symptom. He 
dies, and on opening the body you find distinct traces of enteric 
inflammation. The younger the child is, the less will be the 
chance of fever occurring as a sign of enteric inflammation. It 
seldom happens that this take place after dentition, but before it is 
very common. 

Now, what are the circumstances which would enable us to re- 
cognise this disease in children who have passed the period of first 
dentition? If you find the child vomiting, thirsty, with swelled 
belly, hot skin, a tendency to diarrhoea, and an erythematous red- 
ness about the anus, you may be sure that there is disease of the 
digestive system ; if the child is restless, and you perceive that the 



PATHOLOGY OF ILEITIS. 



87 



symptoms of irritation of the head are coming on, you will be more 
certain, and in such cases pathology will inform you that the dis- 
ease is chiefly in the ileum. In the advanced stage the diarrhoea is 
lessened, but the belly continues tympanitic, the child exhibits 
traces of long suffering, and the circumstance of the teeth not 
being developed gives it the appearance of premature old age, 
which cannot be mistaken by an experienced eye, and is a sign of 
long continued and extensive intestinal disease. In some cases the 
child gets a common attack of diarrhoea ; this is neglected, but 
after going on for two or three days, symptoms of fever begin to 
appear. Here we arrive at a practical rule. Where a child has 
diarrhoea, and, after labouring under this for a few days, gets an 
attack of fever, you may be almost sure that it is a case of enteritis, 
and that you will be acting wisely in treating it as such. In the 
opinion of many well-informed practitioners, that form of fever 
which has been called infantile remittent, is only an example of this 
disease. In proof of this fact, Dr. Marsh, my friend and predecessor 
in this school, in his paper on jaundice, makes some excellent re- 
marks on this subject. " There is yet one form of disease of very 
frequent occurrence, the seat of which is in the stomach and small 
intestines. That to which I allude, is the infantile remittent fever, 
or, as it is vulgarly termed, the worm fever of children. Its charac- 
teristic symptoms, if closely analysed, will be found all of them .to 
point to the mucous surface as the original seat of morbid action." 
— -Dublin Hospital Reports, vol. iii. 

] It would be well for medicine, if the valuable information con- 
veyed in Dr. Marsh's paper was more universally diffused. I feel 
convinced that many children fall victims to malpractice under 
circumstances of this kind. A child gets symptoms of diarrhoea, 
has irregular or bad appetite, and swelled belly. The disease is 
called worm fever ; he gets a dose of calomel and jalap, and, per- 
haps, passes some worms ; for, when we come to speak of worms, 
we shall find that disease of the mucous surface is intimately con- 
nected with worms, and, in the opinion of one practitioner, worms 
may be the result of enteric inflammation. Well, some worms are 
passed; the purgative is again used; the child may not pass any 
more, or he may pass one or two in a week, to encourage the 
practice. But all the symptoms of intestinal inflammation, the 
diarrhoea, the tympanitis, the thirst, the fever, are supposed to 
depend upon the presence of more worms, and these are to be 
evacuated by purgative medicine ; and thus the affair goes on, 
until the child falls into tabes mesenterica, or gets sympathetic in- 
flammation of the brain, and dies of hydrocephalus. I regret to 
add, that in many cases of this kind the head alone is opened ; a 
little fluid is discovered in the ventricles of the brain, the doctor's 
diagnosis of the head is found to be correct, and all parties are 
satisfied. In cases of this kind, the early application of leeches to 
the belly, the regulation of diet, keeping the bowels gently open by 
enemata and mild counter-irritation, would have saved the patient. 



88 



STOKES'S THEORY AND PRACTICE. 



This is not mere theory ; it is but a statement of facts, supported 
by the experience of practical men. 

Tabes Meskjvterica. — I wish to say a few words here with respect 
to tabes mesenteric a. In a course of lectures like the present, it would 
be impossible to examine, in detail, the different forms of this disease : 
it will be as much as I can do to draw your attention to the general 
principles of its pathology and treatment. The term, tabes mesente- 
rica, is employed to designate that species of consumption which 
depends upon disease of the mesenteric glands. The common idea 
formerly entertained with respect to this affection, and, I believe, still 
to a great extent, is, that the disease first commences in the mucous 
glands, and from these extends to the lymphatic ganglia of the 
mesentery, which, in their turn, become enlarged, thickened, and 
less pervious, so that a sufficient share of nutriment cannot be 
absorbed., the consequence of w r hich is, that the patient dies of 
atrophy and exhaustion. With such views of the case, the prin- 
ciples of treatment consisted in employing a class of medicines 
called deobstruent, the operation of which was supposed to be 
efficacious in removing this obstruction, this deposition in the sub- 
stance of the mesenteric glands, and the* enlargement by which it 
was accompanied. This was, and this, I am sorry to say, is the 
idea still entertained by many. What is the actual state of the 
science w T ith respect to this disease? It is found that the glands 
are certainly changed in their structure, and that they are mani- 
festly enlarged ; but this is only a link in the chain of phenomena, 
for it has been proved that in the majority of cases the disease is 
ushered in by enteritis, and that the swelling of the glands is the 
result of disease, propagated along the course of the lymphatics 
from the mucous surface cf the intestines to the mesenteric 
ganglia. This preparation, which I shall send round, will give 
you an idea of the actual state of the disease. Here is one of the 
glands which has been cut through ; it exhibits the cheesy texture 
commonly observed in this disease, but you can perceive there are 
a number of lines running towards each of the glands ; these are 
the engorged lymphatics, which, you see, correspond with ulcers 
on the mucous surface of the small intestine. That this is the 
true pathology of the disease will appear from the following cir- 
cumstances : — First, it has been proved that the glands of the 
mesentery commonly become inflamed, enlarge, and suppurate, in 
cases of inflammation of the mucous membrane of the intestinal 
canal in the adult. A patient gets enteric inflammation and dies ; 
on dissection, we find distinct marks of disease in the intestines, 
and, in addition to this, we find the glands evidently diseased. 
Here is one fact. In the next place, it has been proved that, in a 
great many cases of tabes mesenterica, if you retrace the history of 
the disease, if you go back to its first and earliest phenomena, you 
will find that it began with the symptoms of w<hat has been termed 
remittent fever, or that the patient had enteritis or diarrhoea, which 



PATHOLOGY, ETC., OF TABES MESENTERICA. 89 

afterwards became chronic, and that then the symptoms of tabes 
mesenterica began to appear. In the third place, you will find 
that, in a vast number of cases, where a fatal termination has oc- 
curred, if you pursue your dissection, and slit up the whole of the 
ileum, you will discover numerous old ulcerations of the mucous 
' membrane, and find that the lymphatics which correspond with these 
! ulcerations are in a state of manifest disease. Lastly, it has been 
! observed that the best treatment for tabes mesenterica is that which 
| is calculated to remove enteric inflammation, and that theoldtreat- 
! ment, founded on the principle of removing obstruction, by the use 
j of alkalies, absorbents, and solvents, is erroneous and false in the 
I majority of cases. So that we have proof of the origin of this 
disease in intestinal inflammation, drawn from the occurrence of 
| analogous affections in the adult, from the phenomena of the disease 
! in its early stage, from morbid anatomy, and from treatment. I 
think there can be no doubt that, in most instances, it commences 
: by intestinal inflammation. Of course a predisposition to disease 
1 of the glandular system will favour the occurrence. But is there 
! no case in which the disease has commenced in the glands, and 
where the mucous membrane of the digestive tube is secondarily 
engaged ? My answer to this question is, in a few cases we can- 
not prove that the disease commenced in the mucous membrane, 
and there is no reason why the glands of the mesenterica should 
not be liable to primary tuberculous or scrofulous deposition as 
I well as those of any other part of the body ; but in a vast number 
of instances, the enlargement of the mesenteric glands is secondary, 
and resembles the inflammation of the inguinal glands which re- 
sults from chancre on the penis. I would advise you to consult 
' the Commentaries on Pathological Propositions by Broussais. On 
this subject, also, Dr. Mackintosh's Practice of Physic. 

There is one thing more connected with this disease, which is of 
considerable importance, and to which I shall briefly draw your 
attention, and this is, that this inflammation of the glands of Peyer 
and Brunner, this dothin enteritis, as it has been called, is a very 
common cause of slow convalescence in fever. You will meet 
with cases of fever, which will go on to the 17th or 21st day, and 
i then something like a crisis takes place ; you expect that from this 
time forward the patient will get progressively better ; but in the 
course of a few days you will be surprised to find no amendment, 
and that he is not gaining strength ; you feel his pulse, and find it 
quick and small, his attendant informs you that he is restless at 
! night, and when you ask him how he feels, he says he has no 
! particular complaint, but that he is very weak, gets no sleep at 
I night, and has no appetite. Under these circumstances you are 
anxious to find out what his disease is ; you inquire into the state 
of the heart, lungs, and brain ; you find no evidence of disease in 
any of these organs ; you run over in your mind the symptoms 
present, the feverishness, quick pulse, want of appetite, restless- 
ness, and finding some degree of abdominal tenderness and tym- 

9 



I 



90 



STOKES'S THEORY AND PRACTICE. 



panitic swelling, you arrive at the conclusion that the return of 
health and strength is impeded and delayed by the existence of a 
dothin enteritis. The first person who discovered this fact was 
Dr. Cheyne. " In these cases," says he, " the distress of the patient 
often bore no proportion to the danger he was in ; the former was 
very little, while the latter was extreme. The disease would pro- 
ceed without violent symptoms ; nay, a patient would seem to be 
recovering, although without any critical discharge ; he would 
call for full or middle diet, and for days take his food regularly. 
The only circumstance in his situation which demanded attention 
was, that he regained neither flesh nor strength, and he expressed 
no desire to leave his bed. Then, his pulse again became quick 
and his tongue dry ; and he would complain of dull pain and un- 
easiness in his belly, attended with soreness on pressure, and a 
degree of fulness in the upper part of the abdomen. Then came 
on a loose state of the bowels, and great weakness. Probably at 
the next visit the patient was lying on his back, with a pale sunken 
countenance, and a very quick pulse ; his mind without energy. 
Then his stools (mucous) passed from him in bed, and the urine 
also. Perhaps a hiccup came on ; next his breathing became fre- 
quent, in which case death was at no great distance." In all these 
cases the mucous membrane and glands were found in a state of 
decided disease. 

Now, what was the nature of this disease ? It came on as a 
secondary affection during the course of fever, became more marked 
and intense, and finally destroyed the patient. I have seen very 
many cases of this disease. I give you this as a general rule : — 
when, after the apparent termination of a fever, your patient con- 
valesces very slowly and imperfectly; when you find that he is 
becoming weak, that his pulse is quick, his belly tympanitic, his 
thirst still present, and all this without evidence of disease in the 
respiratory, circulating, or nervous system, you may suspect in- 
flammation of the mucous glands of the digestive tube, which may 
terminate in deep ulcerations ; and you will not be surprised if your 
patient should be carried off by rapid peritonitis, occasioned by an 
ulceration of all the coats of the intestine. I have witnessed many 
instances of the truth of this statement. 

It has been objected to the doctrine, that infantile remittent fever 
and tabes mesenterica depend on inflammation of the mucous 
membrane of the digestive tube, because it has been found that 
purgatives are sometimes useful in the treatment of the disease ; 
and those who bring forward this objection ask, " if purgatives 
give relief, how can it be intestinal inflammation ?" Now, what 
are the real facts of the case 1 These cases, which have been 
relieved by purgatives, are cases in which purgative medicine has 
been give in the early stage, and has been productive of benefit ; 
or, in other words, where the disease is only just commencing, and 
where its cause is proved to be the presence of irritating matter in 
the bowels. A physician is called to a case of this kind ; he gives j 
a purgative ; a quantity of offending matter is evacuated, and thei 



TREATMENT OF ILEITIS. 



91 



child gets better. Yet should act in the very same way. and have 
recourse to purgatives whenever you have reason to suspect the 
existence of irritating or indigestible matter in the bowels. You 
are to employ purgatives on the same principle as every one em- 
ploys emetics in cases where corrosive poison has been swallowed ; 
but no one is inclined to think that he will be able to cure the dis- 
ease by the continued use of emetics. But, unfortunately, persons 
do not attend to the actual state of the digestive tube ; they go on 
prescribing purgative after purgative, until the irritation, which 
was originally produced only by indigestible matter, becomes exa- 
cerbated, and terminates in ulceration of the intestinal mucous 
surface, accompanied by all the symptoms of tabes mesenterica. 

The treatment of this affection is both simple and easy, particu- 
larly when the patient applies to you at an early period. In the 
case of children, one of the first things you have to determine is, 
whether you shall have recourse to the employment of purgatives 
or not. If you happen to be called in at an early period, or if the 
patient has taken no purgatives, and there is reason to suspect a 
loaded state of the bowels, you will be right in employing some 
-mild laxative. You cannot commence your treatment better than 
by prescribing some mild opening medicine, particularly when you 
discover that the patient has been taking indigestible improper food. 
This plan I think both reasonable and useful. You will frequently 
meet with cases in which all the bad symptoms will disappear after 
the use of a few laxatives. Here is a point on which the followers 
of Broussais erred. They declared that the exhibition of a single 
laxative would be to endanger the patient's life ; and that the only 
treatment which could be relied upon consisted in the use of leeches, 
low diet, and cold water. But I think there is as much reason in 
giving a laxative to remove indigestible matter from the bowels in 
a case of this kind, as there would be in giving an emetic in a case 
of gastritis produced by the presence of indigestible matter or cor- 
rosive poison in the stomach. But if, after having evacuated the 
bowels, the symptoms of intestinal irritation should continue, you 
are not to persist in the use of purgatives ; change your hand, and 
attack the symptoms of intestinal inflammation, which have now 
decidedly commenced. 

We should occupy ourselves, gentlemen, at our next lecture, in 
considering the treatment of this disease in the adult as well as 
children, and then go on to the disease of the large intestines. 



LECTURE IX. 

Treatment of ileitis — Advantage of leeching — Stimuli sometimes beneficial — Infantile 
remittent fever — Inflammation of the mucous membrane — Enteritis with diarrhoea — 
Effects of opium in inflammation of serous and mucous membranes — Pathology and 
treatment of diarrhoea and dysentery — Perforation of the intestine — Diseases of the 
large intestine. 

We shall be occupied to-day in considering the treatment of in- 
flammation of the mucous membrane of the small intestine. You 



STOKES'S THEORY AND PRACTICE. 



may recollect that in my last lecture I spoke of the employment of 
laxatives in this disease, and mentioned that we are to employ 
laxatives in enteritis, on the same principle as emetics are used in 
cases where corrosive poison has been taken into the stomach. We 
are not to expect to be able to cure the disease by the use of laxa- 
tives, nor are we to have recourse to them in every case ; we employ 
these remedies where we have decided evidence of the existence of 
offending matter in the bowels. We may meet with a case in the 
early stage, under such circumstances that the removal of the irri- 
tating matter by judicious purgation may completely relieve the 
patient, and this, I believe, is the foundation on which the super- 
struction of the British purgative practice in ileitis and tabes 
mesenterica was raised. It was concluded that a laxative treat- 
ment, which had on many occasions succeeded in removing the 
first symptoms of the disease, would necessarily cure it in all stages 
and cases. This, I need not tell you is wrong. Whenever you 
give purgatives or laxatives in enteritis, bear this in mind, that the 
effect which you have to produce is to be brought about at the least 
possible risk. If you can unload the bowels with a little castor oil 
or rhubarb, or some mild neutral salt, it is much better than to 
have recourse to calomel, or scammony, or colocynth. As a ge- 
neral rule, drastic purgatives must be avoided in inflammation of 
the mucous membrane of the intestines. The school of Broussais 
committed an error, on the one hand, by never admitting the use 
of laxatives, and British practitioners have been wrong, on the 
other hand, by giving too much purgative medicine. The error 
of the latter arose from looking always upon purgatives as anti- 
phlogistics, which they are certainly, so far as they contribute to 
relieve inflammation by causing an increased secretion from the 
intestinal mucous surface. But this increase of secretion can be 
produced only by stimulating the organ to which they are applied ; 
and hence, before they can become general antiphlogistics, they 
must of necessity be local stimulants. Further ; if in a case of 
inflammation of the digestive tube you prescribe a purgative, and 
it fails in causing an increase of secretion, it will add considerably 
to the existing inflammation. It is, however, of very great import- 
ance that there should be no accumulation of offending matter in 
the bowels ; and hence, when you find a degree of fulness in the 
belly, and the dejections scanty, you should always give a laxative 
and follow it up by the administration of a narcotic. By using ene- 
mata, you can do a great deal of good, and this without any injury 
to the digestive tube ; and I think they may be always employed 
with benefit in disease affecting the ileum. Recollect, gentlemen, 
what I wish to impress upon you respecting this part of the treat- 
ment is that laxatives are to be employed in ileitis as one of the 
means of cure ; but you are not to expect that a cure by the use of 
these alone will always be a matter of constant occurrence. It is 
true that many cases presenting symptoms of enteritis, have, in the 
beginning, yielded to laxatives ; but it is true, also, that horrible 



TREATMENT OF ILEITIS. 



93 



mischief has been done by their continued or indiscriminate em- 
ployment. 

A few observations now with respect to bleeding. There is in 
simple inflammation of the mucous membrane of the intestines this 
peculiarity — it very seldom happens that it is necessary to use the 
lancet. The whole class of intestinal inflammations is so generally 
accompanied, even in the early period, with marked prostration 
and a typhoid condition of the whole system, that general bleeding 
is very seldom employed. But when the disease is recent, the 
constitution vigorous, the patient young, the skin intensely hot, 
and the pain violent, (a combination of circumstances which is not 
of very common occurrence,) you may employ the lancet with 
safety and with great advantage to your patient. But what I wish 
to impress upon you is this — you must not expect to cut short an 
attack of enteric inflammation by general bleeding. Over inflam- 
mations of mucous membranes in general, but particularly of the 
intestinal mucous surface, the lancet has comparatively but little 
direct power ; it is in the inflammatory affections of parenchyma- 
tous tissues and serous membranes, that we generally observe the 
most brilliant and decided effects of venesection. Neither can you, 
as in parenchymatous inflammation, bleed a second and a third 
time with benefit. In cases of inflammation affecting the mucous 
membrane of the intestinal canal, you are to look upon venesection 
as a preparatory step to leeching. Where the pain is violent, the 
fever high, the attack recent, and the constitution strong, you will 
do well to bleed ; but only bleed once, and then apply leeches in 
abundance over this suffering organ. There is nothing of more 
importance, nothing of such decided value, as bleeding by leeches 
in inflammation of the mucous membrane of the intestinal canal, 
and here we arrive at a fact, the explanation of which is involved 
in much obscurity. A patient is attacked with inflammation of the 
mucous membrane, and glands of the digestive tube, twelve or 
twenty leeches are applied to the integuments of the abdomen, and 
their application is followed by extraordinary relief. This is a 
very curious fact when we consider that between the place where 
we apply the leeches, and the tissue which is affected, there inter- 
vene skin, cellular membrane, superficial fascia, cellular membrane 
again, deep-seated fascia, muscular substance, cellular membrane 
again, two layers of peritoneum, and muscular substance enveloped 
in cellular tissue. Yet notwithstanding this extraordinary succes- 
sion of tissues, it is an undeniable fact, that the application of a dozen 
! leeehes to the surface of the belly will frequently cut short an intes- 
j tinal inflammation, or materially diminish its intensity. Here is a 
( fact, the explanation of which is extremely difficult; and I tell you 
! candidly, I cannot explain it. The school of Broussais attempt to 
explain it as follows. They state that it is a constant law of the 
economy, that there is a strong sympathy between the internal 
parts and their respective integuments, but they do not say why 
this sympathy should exist. We frequently, however, observe facts 



i 



94 STOKES'S THEORY AND PRACTICE. 

confirmatory of this law ; you are aware that it often happens, that, 
in cases of the deep-seated muscular phlegmon mentioned by Mr. 
Crampton, in abscess of the liver, and in empyema, we have a 
swelling of the integuments, showing the existence of a sympathy 
between the integuments and the internal organs. 

In treating a case of inflammation of the small intestine, I think 
you may generally commence with the application of twelve or 
eighteen leeches over the ileo-ccecal region.* The ordinary result 
of this application is, that the pain and tympanitis are reduced, and 
the thirst diminished; but the patient still has fever, and you are 
to bear in mind that the mere subsidence of pain does not imply the 
removal of the disease. We may modify the character of an ileitis 
very considerably by a single application of leeches, but we are not 
on that account to expect that we shall be able to remove the dis- 
ease entirely. In general it is necessary to apply them two or three 
times, lessening the number at each succeeding application, and 
taking care that they are applied in the proper place, that is, mid- 
way between the umbilicus and the crest of the ileum. Many 
practitioners are afraid of employing leeches in the advanced stage 
of this affection, in consequence of the great debility which cha- 
racterizes the advanced stage of this, as well as inflammation of 
every other part of the digestive tube. But though I am quite of 
opinion that the school of Broussais is wrong in using them at any 
period, still I think they may be employed even where the disease 
is advanced, particularly if they have not been used before, and I 
have frequently seen leeches applied with advantage as late as the 
twelfth day. I have employed them myself in the Meath Hospital 
as late as the ninth and tenth days with decided benefit. Many 
physicians on the continent are in the habit of treating inflamma- 
tion of the digestive system by the application of leeches to the 
anus, and this is said to have a very good effect, and the number 
of leeches required is smaller. In disease of the great intestine 
accompanied by diarrhoea, tenesmus, and tormina, I think this is 
an excellent mode, but when the disease is in the upper part of the 
tube, I prefer applying them to the belly over the situation of the 
inflamed organ. 

Now with respect to internal medicines. In this disease every- 
thing that is administered should be given with the view of remov- 
ing irritation, and for this purpose I know no better preparation 
than a combination of ipecacuanha and opium, as in Dover's 
powder. The exhibition of the compound powder of ipecacuanha 
is attended with decided advantage. You are all aware of the long 

* [Twice or even three times this number of our common American leech 
may be applied in such a case. If leeches are not at hand, we should not be back- 
ward in having recourse to the lancet. I have employed venesection largely and 
repeatedly in the case of a person who was neither young nor robust, but in 
which there was much pain and an active pulse; and with this good effect, in 
addition to his recovery, that, whereas he used, previously, at not long intervals, to 
have frequent attacks of ileitis, he has not had, subsequently, a return of the disease 
for a period of fifteen years past. — B.] 



TREATMENT OF ILEITIS. 



95 



established use of ipecacuanha and opium in diseases of the intes- 
tinal canal, and think there can be no doubt that they possess 
considerable utility. With this I generally combine some mild 
mercurial ; the best you can employ is the hydrarg. cum creta. 
Give two or three grains of each every second or third hour, as 
the case may be, and you may continue this for several days. 
Where there is no diarrhoea, and the bowels have a tendency to 
be constipated, it will be necessary to order, every second or third 
day, a mild laxative, a little manna, or rhubarb, or some castor 
oil; you should insist on the daily use of enemata, and if they 
answer the purpose sufficiently I would advise you to be sparing 
of the use of laxatives by the mouth. In addition to these reme- 
dies, I am in the habit of giving a considerable quantity of gum 
Arabic, which appears to have an extraordinary efficacy in dis- 
ease of the small intestine. I look upon it as peculiarly valuable 
in the diseases of children. The ordinary mode of prescribing it is 
to give a certain quantity of gum water. If this is insufficient, you 
should order half an ounce or an ounce of the gum to be dissolved 
in a pint or quart of water, which the patient is to use during the 
day. After the use of the hydrarg. c. creta and Dover's powder, 
this has a decided value in the treatment of ileitis.* 

In this way by leeching, mild laxatives, prescribing mercury 
with chalk, and compound powder of ipecacuanha with gum water, 
your patient begins to improve. The tenderness of the epigastrium 
disappears, the tongue begins to clean, the fever diminishes, the 
thirst goes off, and appetite returns. This is the favourable termi- 
nation. When the patient is of a weak and delicate habit, it is of 
great importance to pay particular attention to supporting the 
strength, even from an early period of the disease. In such a 
case, after the first week, the physician who neglects the proper 
means of supporting his patient's strength does wrong, and it has 
justly been remarked, that a practitioner will be right in supporting 
the general strength, at the same time that he is employing local 
antiphlogistics. It is in steering clear between these two opposite 
dangers that the judicious practitioner is seen ; he does not allow 
his patient to die of inanition, while at the same time he takes 
care to remove local inflammation. I have seen several experi- 
enced physicians prescribe leeches to the abdomen on the same day 
that they ordered the patient to have chicken broth, and even a 
little wine. There is nothing improper in this ; an inexperienced 
practitioner, who has his eye merely on the local inflammation, is 
apt to fall into the error of overlooking the constitutional debility, 
and allowing it to steal upon him. He finds very little difference 
between the appearance of his patient this day and the next, and 
thinks the slight increase of debility undeserving of any attention. 

* [I have given with advantage, in ileitis, the blue mass in small doses, eay 
three grains three times a day ; and have found warm fomentations by stupes and 
cataplasms on the iliac region serviceable. — J3.] 



9G 



STOKES'S THEORY AND PRACTICE. 



At last his patient begins to sink visibly, he gets alarmed and has 
recourse to stimulants, but it is now too late. Besides, there are 
several articles of diet which support strength, without increasing 
inflammation ; as, for instance, chicken broth, sago, arrow-root, 
strained rice, &c. These do no harm, and they prevent the patient 
from falling into a dangerous typhoid condition. Let us look at 
this in another point of view. Suppose you are called to a child 
who is said to have had an attack of worms, or bilious derange- 
ment, or that his bowels were costive, and purgatives were given, 
that the discharges were found to be bad, and more purgatives 
were administered ; or suppose you are called to a child of a weak 
scrofulous habit, who had been taking large quantities of purgative 
medicine, for what has been termed derangement of the bowels, and 
you find the little sufferer with pale, shrunken face, a black circle 
round his eyes, cold extremities, rapid faltering pulse, great thirst, 
and evident symptoms of increased cerebral excitement ; the little 
arms and hands are cold as death, but the belly burning, tympanitic, 
and very sensible to pressure, and when you compare the radial 
artery with the femoral, as it turns over the pubis, you will have 
some conception of the excited condition of the abdominal vessels; 
and in addition to this train of morbid phenomena, you find there 
is suppression of urine. Are you to attack these symptoms with 
antiphlogistic means? 'No; the first thing you are to do, is to 
prevent any further mischief, by totally inhibiting every kind of 
purgative medicine. You are next to consider carefully what the 
best line of treatment to be pursued is, for here you are under 
circumstances of difficulty, and have a great many prejudices to 
contend with. What I find generally to be most successful is this. 
I begin by taking proper steps to support the strength, ordering the 
patient to take chicken broth, arrow-root, or jelly ; the extremities 
are to be wrapped up in warmed flannel ; and if the patient is sink- 
ing, and has his mouth and teeth crusted with dark sordes, a little 
wine, watching its effects. If it produces sleep, if the pulse comes 
down under its use, and the fever is not increased, it will do a great 
deal of good, and you can gradually increase the quantity. Always 
bear in mind that there is a certain period in all inflammations, in 
which stimulants prove to be antiphlogistics, a circumstance which 
has been overlooked by the school of Broussais. So far with re- 
spect to constitutional treatment ; but what will you do with local 
disease? The application of blisters is of decided use, nay, I have 
seen a few leeches very effective. Apply a blister to the abdomen, 
and dress it with mercurial ointment, at the same time you may 
employ frictions with mercurial ointment ; you will also swathe 
the belly with flannel, so as to keep up a comfortable temperature. 
In this way you will be able to do a great deal of good. You will 
also prescribe hydrarg. c. creta, with Dover's powder ; and if the 
bowels are confined, emollient injections. By steadily pursuing this 
plan of treatment, you will often rescue from imminent danger a case 
which would prove fatal under the purgative plan, and you will 
add greatly to your own reputation. 



TREATMENT OF ILEITIS. 



97 



There is one form of this disease in which diarrhoea is a promi- 
nent symptom, where the purging is from the very commencement. 
On this form I am anxious that you should have clear ideas. In 
cases of this kind there is a copious discharge of fluid matter from 
the bowels. In the majority of cases you may lay down this law, 
that where there is a decided irritation of any secreting organ, in- 
creased discharges from the surface of that organ give more or less 
relief. Suppose two cases of hepatitis ; in the one we have no 
secretion of bile, in the other the secretion is copious ; the latter is 
certainly most favourable. Again, suppose two cases of bronchitis ; 
in one there is a copious expectoration, in the other it is extremely 
scanty; now every medical man-knows that the former is more 
easily managed. The increased secretion of any organ in the 
early stage is to be looked upon as a relief to the inflammation. 
The practical inference to be deduced from this is, that we should 
be cautious in adopting any means of arresting this discharge, as 
it is one of the modes which nature employs in relieving the irri- 
tation of a suffering organ. Well, then, suppose you have a case 
of enteritis, and that on the first or second day diarrhoea sets in, 
what does the routine and systematic physician dol He gives 
chalk mixture and opium with tincture of kino and catechu, and 
what is the consequence 1 The belly becomes tympanitic ; the 
pain is increased, and even peritonitis may supervene ; — this is one 
result of the increase of inflammation ; or the breathing becomes 
difficult, and the patient gets bronchitis or pneumonia. Diarrhoea 
occurring in the early period of this disease is not to be interfered 
with, except when it gets to such a height as to threaten the pa- 
tient's life ; and where it increases his sufferings by the frequency 
of the discharges. In the first week or fortnight, when there are 
only three or four discharges, or even five in the twenty-four hours, 
I believe it is better not to interfere by prescribing direct astringents ; 
but in the advanced period, when the powers of life are low, or the 
discharges very copious, then the physician comes to the assistance 
of nature with just reason, and in such cases you should always 
interfere. The best mode of managing diarrhoea of this kind is to 
employ small, frequently repeated doses of Dover's powder, with 
anodyne injections. And here I may mention briefly, to such of 
you as have not seen them used, the best way of employing them. 
As these injections are used on a different principle from the com- 
mon, the latter being intended to empty the great intestine and be 
discharged, the former to be retained, we are constantly to make 
the basis of our anodyne injection in such a manner, that it will 
not prove stimulant from its bulk, or from any irritating substance 
it may contain. Mucilage of starch, new milk, or linseed decoc- 
tion may be used as the basis, and the quantity taken for one 
injection should never exceed three ounces. To this, for an adult, 
you add from fifteen to thirty drops of tincture of opium, for it is a 
curious fact connected with this subject, that opium given by the 
rectum has frequently been observed to exercise a much morepow- 



98 



STOKES'S THEORY AND PRACTICE. 



erful effect on the system than when an equal or even smaller 
quantity has been taken by the mouth. The rule then is, that 
when you first make trial of the remedy in this manner, feel your 
way cautiously, and if you find that your patient bears ten or 
fifteen drops, you can increase the quantity on repeating the enema. 
An eminent practitioner of this city thinks the narcotic effect of 
opium by the rectum much better marked than by the mouth, and 
I believe this to be true in many instances. I believe the adminis- 
tration of opium in this way requires a good deal of caution. I 
recollect the case of a man who had been for a considerable length 
of time in the habit of using laudanum in large quantities, and 
was, in fact, a regular opium eater. During an attack of illness 
he got an injection containing sixty drops' of laudanum; this pro- 
duced, in a very short time, symptoms of decided narcotism, from 
which the patient never recovered ; in fact, he died with every 
appearance of being poisoned by opium. 

There is another fact with respect to this disease which I would 
have you to bear in mind, that, under certain circumstances, inflam- 
mation of the small intestine will produce a remarkable tolerance of 
opium. This applies not only to the advanced stage of enteritis, but 
also to many other forms of disease. Some time since I made a 
series of clinical experiments with the view of ascertaining the power 
which opium possesses in relieving inflammation, and the result has 
been, that in many cases where the powers of life are so low that we 
cannot have recourse to the lancet, or any kind of depletory measures, 
opium alone furnishes us with a powerful means of subduing 
inflammatory action. When we come to treat of peritonitis, I shall 
have occasion to speak of the good effects of very large doses of 
opium, particularly in that form of disease which results from intes- 
tinal perforation. My first trials of this remedy were in affections 
of serous membranes, and to this I was led by some interesting 
clinical experiments made by Dr. Graves. I next tried it in diseases 
of mucous membranes, where antiphlogistics were inadmissible, and 
here, as in the former cases, I had many proofs of its great efficacy. 
I shall state the particulars of a very remarkable case. A young 
gentleman, a pupil of mine, and a member of the* class at Park 
street, of an irritable habit, was attacked with intense inflammation 
of the mucous membrane of the intestines. He had a high degree 
of fever, and his thirst was so insatiable that for two days he never 
ceased calling for drink. His pulse was weak but rapid ; his 
tongue red and pointed ; respiration very much hurried ; but the 
stethoscopic signs of disease of the lung were absent. His belly 
was exceedingly tender on pressure; and he had another remarkable 
symptom — constant smacking of the lips. The case, as you may 
perceive, was one of severe gastro-enteritis, and it was treated in 
the ordinary mode, by leeches, cold water, &c, but the disease 
showed great obstinacy, and at the end of a month the patient was 
evidently in a state of imminent danger. At this period a curious 
revulsion took place : the chest became engaged, and the patient 



TREATMENT OF ILEITIS. 



99 



got bronchitis. For this he was blistered, and took the decoct, 
polygalse with large doses of carbonate of ammonia, under the use 
of which he recovered. The bronchitis disappeared, but was 
almost immediately replaced by symptoms of intense gastro-enteric 
inflammation, thirst, quick pulse, tympanitis, low delirium and sub- 
sultus tendinum. In the course of two or three days diarrhoea 
come on, becoming more profuse as it advanced. The first day he 
had four discharges, the next eight, and thus it went on increasing 
until there was a constant discharge of thin fluid matter from the 
anus. The patient was quite run down, and on three different 
occasions his friends thought him dead. Having made an unsuc- 
cessful trial of various stimulants and astringents, I determined to 
try what might be expected from large doses of opium. The 
patient was dying, and it was necessary to do something instantly 
which would be likely to arrest the diarrhoea. I ordered a grain 
of opium to be given every hour; on the first day he took twelve 
grains with apparent benefit, the next day he took six, the same 
quantity on the third day, and on the fourth the diarrhoea had so 
much diminished, and the young gentleman was so much better, 
that I thought it might be safely omitted. From this period my 
patient recovered rapidly. I would not bring forward this case in 
proof of the efficacy of opium if there were not many others of a 
similar kind ; and I have no doubt that this was a cure effected by 
the use of opium in large doses. In the treatment of this disease 
by opium, there is one simple rule, by observing which you will be 
able to avoid all difficulties, and at the same time have a criterion 
to judge of the value of the opiate treatment. If the remedy pro- 
duces the ordinary narcotic effects of such large doses on the 
system, it will not do much good. You begin, therefore, cautiously ; 
and if, after the first or second dose, you find that decided narcotism 
is produced, or at least more than you w r ould think the quantity 
given could have brought on, give it up — it will be dangerous. But 
if he bears one, two,~ or three grains, or if, after having taken six 
or eight grains in the twenty-four hours, he appears to be improving, 
you may then persevere in the administration of opium, and it will 
be attended with decided advantage.* 

* [Ileitis, as examined and explained by Dr. Stokes, is the same disease as the 
dothinenterilis of Breton neau, the follicular enteritis of Andral, the mucous fever 
of Rcederer and Wagler, the adynamic g astro-enteritis of Broussais, and the 
typhoid fever or affection of Louis, Chomel, and others. In England and in the 
United States, it has sometimes, but erroneously, been designated as typhus fever. 
The lecturer, it will be remembered, does not think that the inflammation and or- 
ganic change is confined to the mucous follicles or muciparous glands ; and I believe 
that he is right, in supposing that the intermediate mucous surface participates in 
the lesion. Be this as it may, it seems to me that a summary of the chief features, 
in its progress and termination, of the disease, will not be amiss in completion of 
the remarks in the text, which, although excellent as far as they go, do not place 
the reader so fully in possession of all the accessory phenomena, as could be 
desired. 

Follicular enteritis, is a term which designates the seat of the inflammation, 
as regards the several component parts of the intestinal mucous membrane ; but 



100 



STOKES'S THEORY AND PRACTICE. 



We have next to proceed to the consideration of the pathology 
and treatment of diarrhoea and dysentery; I shall, however, first 

it does not specify with equal distinctness the region of which it is mainly the 
seat. This last is the lower portion of the jejunum, the whole of the ileum, and 
sometimes the upper portion of the large intestine or colon adjoining. The point 
at which the follicular alterations begin, is the end of the ileum and the ileo- 
cecal valve. From this the lesions advance upwards and towards the jejunum. 
The anatomical name given to the follicles or crypts in the digestive mucous mem- 
brane is, the glands of Brunner and of Peyer. The first serve to designate the 
scattered follicles in the stomach and duodenum ; the second, the glands of Peyer, 
are in clusters, and arrayed in rounded and elliptical patches in the lower portion 
of the free surface of the small intestine. In the colon they are found united 
two and two, and four and four, on both its free and adherent surface. Coincident 
with alteration of structure of the follicles is that of the corresponding mesenteric 
glands, as mentioned in the text. 

The first change in the mucous membrane and follicles noticed, is an exan- 
thema, which is soon followed by an increased opacity of these bodies, seen through 
the distended and almost transparent intestine at various parts along its course : 
the succeeding stages are, partial, then entire ulceration, and, when convalescence 
takes place, cicatrization. Another, and more fatal termination, is by perforation 
of the mucous membrane, and consequent partial exposure of the peritoneum: 
resolution may occur, and is of course favourable. There is not any positive 
relation in regard to time of these stages, one to another. Sometimes ulcerations 
of the follicles have been seen in the bodies of those who have died a few days 
after the invasion of the disease. In other cases, again, a simple exanthema, only, 
has been found in persons who had died at a more advanced period of the disease. 
In ninety-two cases closely observed by MM. Louis and Chomel, the ulceration 
commenced at from the eighth to the twelfth or fifteenth day from the first 
attack. In some cases, during the second period of the disease, the mucous mem- 
brane covering the patches becomes of a dark colour, separated from the subjacent 
tissues, and is observed to be perforated with a large number of holes, giving it 
a reticulated appearance; these holes are the orifices of the enlarged follicles. 
If death occurs at a later period, there is sometimes no trace either of the ul- 
cerated or reticulated patches, but merely ulcers. M. Chomel thinks that, in the 
present state of our knowledge, the ulcers which are formed in the intestines 
after an acute disease, are the result of lesion of the follicles, and not a primary 
affection of the mucous membrane. 

The peculiar interest, which at the present time attaches to these anatomical 
lesions in ileitis, arises from the fact of their being those which characterize 
almost uniformly typhoid fever. We are not justified in affirming that this fever 
never exists without alteration of the mucous follicles of the ileum or the glands 
of Peyer; for M. Andral has clearly shown, in his Clinique Medicate, that pa- 
tients have perished under fever marked with all the symptoms of typhoid, and 
yet there was neither exanthema, certainly no ulcerations, nor any appreciable 
alteration in any part of the digestive tube which could explain the cause of 
death. On the other hand, there are other diseases, such as cholera, scarlatina, 
and phthisis, in which the intestinal mucous follicles are altered. After all, how- 
ever, it appears from the observations of MM. Louis and Chomel, Dr. Gerhard 
and others, that, in a very large majority of the cases of deaths from typhoid fever, 
the glands in question were affected. M. Andral makes the proportion as ninety 
to a hundred. Of the forty-tw r o subjects examined by M. Chomel, he found the 
follicles more or less diseased in all of them. 

If we inquire into the alterations of structure of other parts, associated with 
follicular enteritis, we shall find that there is no constancy in this respect in any 
one of them. Sometimes the mucous membrane of the pharynx and oesophagus 
is ulcerated ; and the stomach exhibits various alterations in colour, degrees of 
injection, ecchymosis and softening, but none of these are peculiar; they are met 
with in other diseases. Rarely is there any lesion in the duodenum, or the upper 



TREATMENT OF ILEITIS. 



101 



exhibit a few preparations illustrative of the diseases of the small 
intestine. Here is a preparation of the affection called tabes me- 

four-fifths of the jejunum. Among the lesions occasionally met with in the 
circulatory apparatus, M. Louis notices softening of the left ventricle of the heart. 
When this lesion is present it may serve to explain the weakness of the pulse, 
which we find in some cases of typhoid fever, in the respiratory apparatus, ul- 
cerations of the larynx have been found, and the lungs affected in a majority of 
the cases, — their tissue being engorged or hepatised in different degrees, and re* 
duced to a hard fleshy mass. The usual change in the lungs in fevers of 
an alarming nature, are a livid redness of tissue, which is impermeable to air and 
breaks down under the finger. The secretory organs, and the cellular and serous 
systems are rarely affected to any extent, — if, in the former, we except the parotid 
gland. 

As regards the lesions of the nervous system, we should suppose them to be 
very frequent, were we to infer the fact from the frequency of disorder of the senses 
and of the mental faculties in typhoid fever ; but careful observation does not justify- 
any such conclusion. Lesions of the nervous centres are rare, and of small mo- 
ment in general. 

Of the causes of follicular enteritis or typhoid fever, we are not prepared to 
speak with any degree of confidence. In Paris it has been found that the most 
efficacious cause in the production of the disease is the recency of arrival in the 
capital from the country. I well remember the uniform question asked by 
Lerminier at the ChariteHospital, of a patient with this fever, which he visited 
for the first time. " How long since you arrived in Paris V In reference to the 
predisposition induced by age, it has been found that this disease attacks chiefly 
those between twenty and thirty years of age. 

When it prevails epidemically, follicular enteritis may be greatly modified by 
the extent to which other organs take on associated disease with the ileum. 
Hence, we have the varieties severally of inflammatory, bilious, mucus, ataxic, 
slow, nervous, and adynamic typhoid fever. 

I shall not give, in detail, all the symptoms of this disease, the duration of which 
is commonly from twenty to thirty days. The diagnostic ones are thus summed 
up by M. Andral (Cours de Patlwhgie Interne). Youth ; headache, diarrhoea, 
stupor, delirium, somnolency, petechia*, sudamina, epistaxis, intestinal hemorrhage, 
cough, eschars, particularly on the parts subjected to pressure in lying, fuliginosi- 
ties of the mouth, meteorisrn or tympanites. The petechia commonly show them- 
selves not sooner than the eighth nor later than the fifteenth day : they are chiefly 
confined to the abdomen, and anterior part of the chest ; and besides, their being 
more circumscribed in extent than the petechias of typhus, they are of a rose 
colour. The sudamina are small vesicles, commonly in the region of the neck, 
arm-pits, loins and groins, and formed by a transparent serum which raises the 
epidermis. 

In addition to the loss of appetite, nausea, and foul tongue, which indicate at 
the beginning a disease of the digestive functions, there is commonly diarrhoea, 
sometimes constipation, and a distended abdomen. The pulse is small, feeble, and 
I early compressible, sometimes voluminous ; the skin, at first of an acrid heat is, after 
! a time, moistened with a viscous sweat. Allusion has been already made, to the fre- 
I quent disorder of the senses and of the intellect : the countenance has a wild and 
I haggard expression, which after a time is converted into one of stupidity. Among 
! other symptoms of the disturbance of the nervous system are delirium, sometimes 
! convulsions! and often subsultus tendinum. The time at which the symptoms 
, are aggravated and complicated is usually about the eighth day, when the pe- 
! techise or typhoid spots appear. It is then that there is such a marked expression 
! of stupor in the countenance; red and injected conjunctiva?, and mouth and tongue 
! dry and hard, and covered and lined with a brownish coat (fuliginosity). 
j The convalescence is generally long and tedious, and relapses are of ready occur- 
i rence after any error of regimen or other imprudence. 

| Amidst the conflicting opinions on the proper treatment in this disease, we are 

10 



102 



STOKES'S THEORY AND PRACTICE. 



senterica. You see here various masses of those cheesy glands 
which are generally supposed to be the result of original scrofulous 
deposition ; but if you look among the folds of the intestine, you 
will see a vast number of engorged lymphatics running up directly 
to those glands, and you will perceive that these lymphatics corres- 
pond at their commencement with ulcerative disease of the intestinal 
mucous surface and glands. Here is an interesting preparation, 
exhibiting three distinct ulcers. In one of these you see the bright 
vascularity and turgescence of the areola, and the ulcerative pro- 
cess which has just begun in the centre. Close to this is another 
large ulcer, which has destroyed the texture of the gut down to its 
serous covering, through which you perceive the light is shining. 
The last is an example of perforating ulcer ; all the coats of the 
intestine have been destroyed, and on turning the preparation you 
see evident marks of peritoneal inflammation. This preparation 
also exhibits one of the modes in which an ulcerative perforation of 
the intestine may terminate. Sometimes, at the very moment the 
ulcerative process has succeeded in destroying the last coat of the 
intestine, inflammation of the serous membrane in the immediate 
vicinity takes place, a quantity of lymph is poured out, and if the 
matter be not in great quantity, and the hole not too large, the 
opening is closed up by the effused lymph, and a stop is put to 
further mischief. Again, by the effusion of lymph the ulcerated 
portion of the intestine may form an adhesion to another sound 
portion, the effused lymph does not permit the passage of the con- 
left to infer that the safer course, and it is that which I have myself had most 
reason to be satisfied with, will be to have recourse to venesection in the early 
period, when the fever is high and pulse full. If the pain and distress in the 
abdomen be considerable, leeches to the anus, and, if the head suffer much, leeches 
behind the ears will do good. Cold applications to the head and warm pediluvium j 
or sinapisms to the lower extremities should not be omitted. Of the preference j 
to be given to enemata over purging, although not of course to the exclusion of 
the latter, and of the means of treating the diarrhoea, and the light in which it j ' 
ought to be regarded, I need not say anything additional to the excellent admoni- £ 
tions on these points given by Dr. Stokes in the text. With the subsidence of the | t 
inflammation of the mucous follicles after the first period of the disease may come i 2 
indications for the use of purgatives more freely than at the beginning. Castor- ' . 
oil and turpentine alternately with small doses of calomel, are remedies entitled to ' ; 
our confidence at this period. After these, or such other analogous means as may 8l 
have been employed, we shall find the sulphate of quinine a most valuable \ 
auxiliary ; nor should we be prevented from having recourse to it a second time, i a , 
because our first trials, made somewhat too early, may not have agreed with the ( .' 
patient. 

When perforations of the mucous coat occur, of which increased tenderness of ^ 
the abdomen, and other symptoms of incipient peritonitis may induce suspicion, a m 
fatal result is to be anticipated. Drs. Stokes and Graves in these cases have put into I |j ; 
execution a practice originally suggested by the latter, viz., of giving large and 
repeated doses of opium, so as to preserve the intestines in a complete state of , 
rest, in order to prevent the escape of fsecal matter into the peritoneum, and to c 
allow nature to close the opening by adhesive inflammation. Tiiese gentlemen li 
have had some cases to justify the utility of the practice, and although it has not jff 
often succeeded, yet it has never wholly failed to alleviate this distressing ac- ei 
cident. — B.l 



DISEASES OF THE LARGE INTESTINES. 



103 



1 tents of the intestine into the peritoneum, but does not prevent them 
j from getting into the sound portion by a continuance of the ulcerative 
process, and in this way we have another termination, in the forma- 
j tion of a false passage. Here is a good example of disease of the 
coecum, here is an example of diseases of the colon, and here is 
! another with a vast number of ulcerations. Here is an interesting 
i specimen of disease of the large intestine. The patient to whom it 
| belonged died of phthisis ; — look at it and you will see what exten- 
sive ravages have been made by the ulcerative process. 

We come now to take up the subject of disease of the large 
, intestine, which, as I find my time nearly past, I must reserve until 
our next meeting. I shall then speak of dysentery and diarrhoea, 
l and shall draw your attention to some new and curious facts re- 
specting the discharge of fatty matter from the bowels. In the 
! last number of the Medico-Chirurgical Transactions, three separate 
papers have appeared on this subject from Dr. Elliotson, Dr. Bright, 
and Mr. Lloyd. Dr. Bright has brought forward several interesting 
facts tending to show that discharges of fatty matter may be found 
to be indicative of certain forms of disease of the digestive tube and 
the neighbouring glands. 



LECTURE X. 

Diseases of the large intestines — Treatment of diarrhoea — Apyrexial period of diarrhoea 
— Danger in suddenly arresting the discharge — Purging in phthisis — Dysentery — 
Epidemic dysentery. 

To-day we proceed to the consideration of the nature and treat- 
ment of some of the diseases of the large intestine. You will see, 
in the various systematic treatises on the practice of physic, sepa- 
rate descriptions of the affections of this portion of the digestive 
tube, you will find diarrhoea in one chapter and d}^sentery in 
another, and you will observe, that a great deal of ingenuity has 
been expended in forming nosological differences between these 
affections. I fear that much of what has been written respecting 
them is rather calculated to puzzle and mislead than to inform the 
student. Viewed anatomically, there is no essential difference. 
You may for every practical purpose place them in the same class, 
and consider them as the result of the same morbid condition of 
the same part, namely, an inflammation of the lower portion of the 
digestive tube. Some persons may quarrel with the term inflam- 
mation — call it, then, irritation, if you please ; but the truth is, 
that it is a disease of the lower portion of the intestine ; the results 
of which are increased sensibility and altered secretion; and this 
description, I think, will fairly apply to one as well as the other. 
If a man has purging, with fever and pain, it is called dysentery ; 
if he has purging, without pain, and without any manifest febrile 
excitement, we call it diarrhoea. But, in cases where persons have 
died, after having laboured under diarrhoea for a length of time, we 



104 



STOKES'S THEORY AND PRACTICE. 



generally find, on dissection, lesions of the mucous membrane of 
the intestinal canal, sufficient to account for death. There are 
some cases, indeed, in which the mucous surface takes on a gleety 
discharge, similar to that which follows gonorrhoea, and under 
such circumstances you will not be able to discover any distinct 
anatomical evidences of disease. These, however, are compara- 
tively rare, and bear little or no proportion to those cases which 
present distinct traces of organic lesion. 

On the subjects of diarrhoea and dysentery I shall be very brief, 
as our time is short, and everything relating to the pathology and 
treatment of these affections may be expressed in a very few words. 
First, then, as to diarrhoea, which is the frequent passing of stools 
of a more or less watery consistence, and which may, and gene- 
rally does, occur without fever. This affection may be considered 
to arise under three different circumstances ; but, in point of fact, 
every form of the disease may be referred to a single cause, as 
there is no essential difference in the actual nature of the circum- 
stances by which they are produced. A patient, for instance, 
takes a quantity of indigestible food, this produces irritation in the 
gastro-intestinal mucous surface, and diarrhoea is the consequence. 
Another is exposed to cold, or gets wet feet, the mucous membrane 
of the bowels becomes more or less inflamed, and this terminates in 
diarrhoea. Again, a patient, labouring under hectic, has profuse 
perspirations, these go off and are replaced by frequent fluid dis- 
charges from the bowels — here, also, the result is called diarrhoea. 
All these forms are, however, referable to the same cause — irrita- 
tion of the mucous lining of the digestive tube. 

A man commits an excess at table, eats something that he cannot 
digest, and gets diarrhoea. If you happen to be called to such a 
case at an early period, your course is very plain and easy ; there 
is every chance that the affected organ has received (as yet) no 
material injury, and is attempting to relieve itself by increased 
secretion. The indication here is to get rid of the source of irrita- 
tion as soon as possible, and this is best done by prescribing a laxa- 
tive, to remove the ofTending matter, and then following it up with 
an opiate. The simple rule is to relieve the intestine, and prevent 
the liability to inflammation. A mild laxative, followed by opiates 
and demulcents, keeping the patient on a low regimen for a few 
days, and in a warm temperature ; this is sufficient for the manage- 
ment of the first form of diarrhoea. In point of fact, the principal 
thing which the practitioner has to do, is to watch his patient, and 
take care not to permit the inflammatory action to become 
developed. It is in such cases as these that the expectant medi- » 
cine is of value. What you are to direct your attention to, is 
the state of the intestinal surface. If a patient gets an attack of 
pain, if his belly becomes tender on pressure, if he is more or less 
feverish, you may be sure there has been some mischief done. If, 
on the contrary, the diarrhoea yields to the exhibition of a mild 
laxative and light diet; if the pulse be soft, and the belly not tender, 



DISEASES OF THE LARGE INTESTINES. 



105 



you have no reason to fear. But if the purging becomes more dis- 
tressing, if the pain is severe, the abdominal tenderness evident, the 
thirst and restlessness continue unabated, it is a sign that the irri- 
tation has produced something more than mere increased secretion, 
and that actual disease of the mucous tissue is setting in. We 
have now a true inflammatory diarrhoea, which may be looked 
upon altogether as an enteritis of that kind in which there is a 
copious secretion from the surface of the intestine. You observe 
this leads us at once to the principles of treatment. Here we have 
fever, pain, frequent morbid stools, thirst, and abdominal tender- 
ness. Well, then, what are you to do ? In a case where these 
symptoms are so severe as to excite alarm, at once begin with 
applying leeches. Where there is merely evidence of intestinal 
irritation, caused by indigestible food, give a laxative, and follow 
it up with an opiate; where, in addition to the ordinary symptoms, 
you have fever, pain, and tenderness, never omit the application of 
leeches. Many a time have I seen cases of this kind, in which 
chalk mixture and astringents not only failed but even caused 
additional suffering, speedily and completely relieved by the appli~ 
cation of a few leeches. In using leeches, too, we are not like the 
practitioners who trust to astringents, playing at the game of 
double or quits ; nor do we stop the purging by exchanging it for 
something else equally bad, or even worse, for a peritonitis or a 
bronchitis, for instance ; by removing its cause we not only check 
the diarrhoea, but we obviate any tendency to a metastasis of inflame 
mation to other tissues, and our mode of cure has at once the merit of 
being successful and safe. 

A patient who has had an attack of diarrhoea should have his 
belly swathed with flannel ; this should never be neglected. He 
will also experience a great deal of benefit from the use of the hip 
bath and occasional opiates. Give, also, a combination of rhubarb 
and Dover's powders, and you will find that it will do him a great 
deal of good. This is the remedy which Rcederer and Wagler 
found to be of extraordinary advantage in the mucous fever, with 
diarrhoea, which ravaged parts of Germany in the last century. 
Give two or three grains of each every second or third hour, and 
increase or diminish each of the ingredients according to circum- 
stances, increasing the Dover's powder where the indication is to 
remove pain and irritation, and increasing the rhubarb where you 
wish to produce a laxative effect. This combination forms a 
remedy of decided value in enteric inflammations ; it has been 
much used in such cases by Dr. Cheyne, and I have repeatedly 
employed it in the Meath Hospital with marked advantage. You 
are also to bear in mind, that though the principle of treatment in 
this disease is to remove its cause and put a stop to the purging, 
still you are in no case authorized to give it a sudden check, by 
astringents, in the early period. I gave the reasons for this at my 
last lecture, and showed that it was based upon a general law of 
the economy. If an organ in a state of inflammation pours out 

10* 



106 



STOKES'S THEORY AND PRACTICE. 



an increased quantity of secretion, it is the mode in which nature 
attempts to give relief; and if you suddenly arrest this secretion, 
the probability is, that you will excite more inflammation in that 
organ or cause a metastasis to other parts. This is particularly 
the case if inflammatory fever exists. You must also attend to 
your patient's diet. Your object here is to support him on such a 
diet as will require but little digestive power, and will not produce 
large collections of faecal matter in the bowels. Jellies, arrow-root, 
chicken-broth, and mild farinaceous food, are the only things that 
can be used with safety, until the intestinal irritation has subsided. 
By pursuing this plan of treatment with steadiness and decision, 
you generally succeed in cutting short the disease. In some cases, 
the diarrhoea will run on to the chronic state, just like the gleet 
which follows gonorrhoea ; and this is to be looked upon as the 
apyrexial period, in which antiphlogistic remedies are no longer 
admissible, and where you may employ stimulants and astringents 
with effect. The best way to manage this form of the disease, is 
to make your patient use warm clothing, an even temperature, 
and mild nutritious diet ; to prescribe the vegetable and astringent 
tonics, the hip bath, and the occasional use of mild laxatives, 
followed by an opiate. In this way, after some time, the disease 
generally goes off, and the patient recovers his strength. But it 
may happen that this gleety discharge will continue unabated ; it 
is running the patient down, and he wants some decided remedy to 
check it. Now, the remedies which appear to have the greatest 
power in stopping this discharge, are the metallic astringents, and 
the turpentines and balsams, combined with some of the prepara- 
tions of opium. It is a curious and interesting matter to consider 
how these remedies act. They are a class of medicines which 
exercise an extraordinary influence over discharges from mucous 
surfaces, in a way we do not understand, but the effect is to arrest 
these discharges. In a case of ophthalmia, accompanied by copious 
secretion from the conjunctiva, or in a case of chronic gonorrhoea, 
we know there is nothing more beneficial than metallic astringents 
and balsams ; and we are also aware of the great value which tur- 
pentine and balsam copaiva possess in checking the increased 
expectoration of a chronic bronchitis. In diarrhoea, also, they 
have the same power; they check inordinate secretion, and 
remove the morbid condition of the mucous membrane on which 
it depends, by some effect produced on the surface of that mem- 
brane, but in what manner this is accomplished we know not. In 
severe cases of this gleety discharge, one of the most certain 
remedies we can employ is acetate of lead. You will seldom have 
occasion to use this or any of the other remedies alluded to, in the 
case of a healthy person, because the disease will seldom pass into 
this second or gleety stage ; but if it should, and that it is running 
down the patient, it behoves you to check it as soon as possible,, 
consistent with safety. Give, then, the acetate of lead in free and 
repeated doses, and it is singular to remark what quantities of it 



DISEASES OF THE LARGE INTESTINES. 



107 



patients under such circumstances will bear without any bad con- 
sequence ensuing. Hitherto, many persons have been afraid to 
employ it in large quantities, from fear of producing painters' 
colic ; but at present it is known that this disease is to be attributed 
to the absorption of the carbonate of lead in almost every instance, 
and that the acetate is comparatively harmless. On this point I 
can mention one interesting fact, namely, that I have been in the 
habit of using it constantly, and in considerable doses, for the last 
six years, and I cannot bring to my recollection one single instance 
of colic produced by it. One patient, in particular, who was under 
my care, took it in very considerable doses for six weeks, without 
any apparent injury. The only cases in which I have seen the 
acetate of lead act as a poison, were those in which it had been 
used as an external application. Whether it be that this remedy is 
more pernicious when employed after the endermic mode, or 
whether, when applied to the skin, it attracts carbonic acid from 
the air, and is converted into a carbonate, I do not know, but of 
this I am certain, that where bad effects have followed the employ- 
ment of the acetate of lead, they have been brought on it by its 
external use. I generally use this remedy in the form of pill, pre- 
scribing two grains of the acetate of lead and a quarter of a grain 
of opium, three times a day. With the same intention you may 
employ the turpentines and balsams, which have a powerful effect 
in checking mucous discharges. Dr. Pemberton, in his work on 
Abdominal Diseases, speaks very highly of the efficacy of balsam 
copaiva ;* and I have seen many cases where turpentine has had a 
great efficacy in arresting chronic diarrhoea. You will see, in the 
works of materia medica, some other remedies which you can 
employ with benefit in such cases, but I may mention one which is 
not generally known — the alkali of the nux vomica. Strychnine 
w r as first used in checking mucous discharges by a German phy- 
sician, and afterwards by Dr. Graves in this city. The cases in 
which it proves most successful, are those in which there is a mere 
gleety discharge, a copious secretion from the mucous surface, 
without any inflammatory action whatever, or if there be, where it 
is so low as not to produce the least feverish excitement or pain. 
Cases of this kind, in which strychnine has been eminently success- 
ful, have been published by Dr. Graves. Among others, is that of 
a gentleman, who had sudden calls, so that he often had not time- 
to reach the close-stool. He passed a quantity of thin jelly-like 
substance, and then experienced a transient relief until another 
attack came on. This case was cured by the use of strychnine, 
one-twelfth of a grain, three times a day, made into pills with 
crumb of bread or aromatic confection. 

I may mention here, that, in treating gleety diarrhoea in this way, 

* [Dr. La Roche, of Philadelphia, has recorded his successful experience of 
the efficaey of the balsam m this disease. See Eclectic Journal of Medicine* 
vol. ii„ p. 409-19.— B.] 



103 



STOKES'S THEORY AND PRACTICE. 



one thing should be always borne in mind — it is always dangerous 
to check any copious secretion suddenly, and the danger consists 
in the liability to metastasis" or new inflammation. Never forget 
this. What generally happens is, that the patient's belly begins to 
swell, and you have ascites rapidly formed. Now, I have never 
seen a case do well in which this kind of ascites came on after the 
sudden checking of a diarrhoea ; the patients all died. Another 
consequence is the rapid supervention of pulmonic inflammation, 
and here the disease is almost as bad as in the bowels. You will 
ask how this unfavourable termination may be avoided. The best 
mode is, while you are arresting the discharge from the bowels, to 
promote a determination to the surface. While you are using 
opiates, and stimulants, and astringents, employ general warm 
bathing, or the hip bath, dress the patient in flannel, and use mild 
diaphoretics every night. You will also do right in blistering the 
belly occasionally. In this way you will succeed in curing the 
worst cases of this chronic flux, without exposing your patient to 
the risk of new inflammation, or translation of disease to other 
organs.* 

One of the most common forms of diarrhoea is the purging which 
occurs in cases of phthisis; a physician will be called to treat this 
as often as any other, and it is of importance that you should have 
correct ideas with respect to its pathology and treatment. The 
ordinary opinion is, that this kind of diarrhoea is one of the results 
of hectic fever, and many practitioners, in treating the purging of 
consumptive patients, overlook the actual condition of the intestine, 
and only take into consideration the state of the whole constitution, \ 
of the hectic state of which the diarrhoea is looked upon as one of 
the symptoms. The consequence of this is, that they do not proceed 
on the same principles in the treatment of this as of other similar 
affections of the intestinal canal. Now, I would impress upon you, 
that you should always consider the diarrhoea of phthisis as de- 
pending, in almost every instance, on enteric inflammation. There 
is no fact in medicine better established than this. Persons think it 
is the hectic which produces the purgation, but I believe the con- 
verse of this proposition is often much nearer the truth, and that 
the constant diarrhoea often produces and keeps up the hectic. If 
you examine the digestive tube of a patient who has died with 
symptoms of phthisical diarrhoea, you will commonly find extensive 
ulcerations in the colon, caecum, and ileum. In some cases of con- 
sumption, where the purging has been very severe, the amount of : 
disease will often be found to be quite extraordinary : I have often fl 
seen the whole of the lower part of the tube one sheet of extensive (1 

* [In such a state of things as that recorded in the text I have repeatedly and B 
with the best effect prescribed the blue pill alone, if there be heat and dry J 
tongue, and with opium if the skin is cold and tongue moist. This will be found j 
to be a safer practice than the administration of astringents. If the stomach is 
not oppressed by the balsam copaiba, it may be given in the morning, and the blue 
pill at night. — B.] 



DISEASES OF THE LARGE INTESTINES. 



109 



ulceration. I find I have not brought up any specimens of the 
effects of phthisical diarrhoea from the museum, but will exhibit 
them at our next meeting. The preparations before us are those 
which are illustrative of dysentery? but they will convey to you a 
good idea of the state of the great intestine in the diarrhoea of con- 
sumption, for the effects are nearly the same. Observe now, the 
importance of this fact, and recollect that in treating every case of 
consumption, with diarrhoea, you will have constantly to bear in 
mind this enteric complication. Recollect, also, that one of the best 
means of stopping it, when all other remedies have failed, is a blister 
applied over the abdomen. If the purging depended on hectic, this 
would not be the case. I could bring forward several cases in 
which everything had been tried without success, wben a blister 
was applied to the belly, and from the time it rose the patients 
ceased to be troubled with diarrhoea, and continued so up to the 
period of death. I do not mean that you should in these cases pro- 
ceed to attack the enteritis with the same vigour as you would a 
similar disease in the healthy subject. Generally speaking, I be- 
lieve this form of enteritis to be incurable ; but it is of importance 
that you should be aware' of this enteric complication in phthisis, 
and when you are called in to treat such a case, you should care- 
fully avoid prescribing anything calculated to add to the existing 
irritation.* 

Before I quit this subject, I wish to make one remark by the way 
of caution. It not unfrequently happens that a person, labouring 
under chronic diarrhoea, comes to consult a medical practitioner, 
and tells him that he has been suffering from this complaint for 
months, that he has eight or nine discharges by stool in the day, 
and that he has been under the care of five or six doctors in suc- 
cession, without any benefit. Well, you are determined to have 
your trial, too, and you commence operations by putting him on 
full doses of acetate of lead. After a week or a fortnight, he comes 
back and tells you he is not a bit the better. You then try turpen- 
tine or balsam copavia — no use. Nitrate of silver — the same 
result. The man gets tired of you in turn, and perhaps goes to a 
surgeon to ask his advice. The surgeon examines the rectum 
carefully, and finds, at a short distance from the anus, an ulcer, 
which he immediately touches with a strong solution of the nitrate 

* [I have found, very generally, this form of diarrhoea to be more controlled by 
change of regimen than by active medicinal means. The discharges, from having 
been copious and frequent, and irritating and exhausting, will be reduced to two 
or three in the twenty-four hours, by the substitution of bland farinaceous food for 
that of a more stimulating character, — such as meats, animal broths, &c. The 
patient himself, however craving his appetite may be for strong food, soon sees his 
advantage in at least temporary abstinence, and that his strength is rather im- 
proved than otherwise, under the use of what he contemptuously called slops — 
rice or barley water, and rice or arrow-root boiled into a jelly, and flavoured 
with a little spice and sugar. Of the medicines which I have employed in these 
cases I prefer the simplest,— small doses of carbonate of magnesia with a fourth 
or half a grain of ipecacuanha, and a drink of mucilage of gum arabic. — B.] 



110 



STOKES'S THEORY AND PRACTICE. 



of silver. The ulcer begins to heal, the irritation of the gut ceases, 
and the diarrhoea goes off. The surgeon is extolled to the skies, 
and the doctors disgraced for ever in the opinion of the patient. 
Now this is not an uncommon case. I have seen several instances 
of it, and I must tell you I was once mistaken in this way myself. 
These ulcers are situated close to the verge of the anus ; they 
occur chiefly in persons of broken-down constitution, and those 
who have taken a great deal of mercury. They produce irritation 
in the colon, tenesmus, griping, frequent discharges by stool, and, 
most commonly during the straining, a little blood is passed. 
During the course of last summer, I treated a soldier for this affec- 
tion, who had been discharged from the East India Company's 
service (as was stated in his discharge) for incurable dysentery. I 
examined the rectum, and finding some ulcers close to the anus, 
had them touched with the nitrate of silver. Under this treatment 
a rapid amendment took place, and in the space of three weeks the 
man was discharged, quite cured. Now, are you to make this 
examination in every case ? I believe you will act rightly in 
doing so in every case of chronic diarrhoea in the male, but the 
examination is absolutely necessary in all cases under the following 
circumstances : first, when the diarrhoea has been of long standing ; 
secondly, when it has resisted a great variety of treatment; thirdly, 
when it has been combined with tenesmus and a desire of sitting 
on the night chair after a stool has been passed, showing irritability 
of the lower part of the great intestine ; and, lastly, when the 
patient's health does not appear to be so much affected as it natu- . 
rally should be, where there was long-continued disease of a large 
portion of the great intestine. A patient will come to consult you, 
who will inform you that he has had eight or ten alvine evacua- 
tions every day for the last six months, and yet he eats heartily and 
looks quite well. Under these circumstances, the cause of the 
diarrhoea will generally be found to be ulceration of limited extent j 
low down the tube, and capable of being quickly and effectually 
removed by a strong solution of the nitrate of silver. I shall 
recapitulate all the circumstances under which an examination is 1 
indispensable ; where the symptoms have been persistent, have 
resisted a variety of treatment, are accompanied by tenesmus, and 
where the injury done to the general health is not in proportion to 
the duration of the disease. I may mention here, that a medical 
friend of mine has communicated to me the particulars of another 
case of this form of diarrhoea in a soldier who was invalided on 
this account, and who experienced sudden and permanent relief 
from the application of nitrate of silver to some ulcerated spots 
which were discovered near the termination of the rectum. 

We come now to the subject of dysentery, I shall draw your 
attention briefly to the general principles of the pathology and treat- ; 
ment of this affection ; but I do not intend to enter upon the con- 
sideration of its general history, which you will find sufficiently 
detailed in books. The first principle I have to enforce on this 



DISEASES OF THE LARGE INTESTINES. 



Ill 



subject — and you may take it as an observation based on the 
soundest pathology — is this, that dysentery is inflammation of the 
large intestine. In some cases it is complicated with fever, and in 
others with disease in the upper portion of the digestive tube ; and 
I believe that those cases which are termed epidemic dysentery, 
are those in which this disease is combined with typhus fever, or 
with an extensive affection of the small intestines — where there is 
ileitis as well as colitis. I shall not take up your time with discus- 
sions respecting epidemic dysenteries, or those of warm climates ; 
it will be sufficient, for the present, to allude to that form of disease 
which is observed in this country. 

I have told you that dysentery is an inflammatory affection of the 
great intestine, and all the symptoms during life, as well as the 
phenomena revealed by dissection, tend to confirm this view of the 
subject. We often have fever, because the constitution sympathizes 
with the inflammation of an important organ : we have excessive 
pain and irritation of the intestine, in consequence of its muscular 
fibres being involved in the inflammation ; and we have discharges 
of morbid, purulent, and bloody secretion. You will now please 
to inspect this preparation, and hand it round. See the effects of 
dysentery — the extensive inflammation, ulceration, and sloughing, 
of the mucous membrane. Here is another preparation; you per- 
ceive the whole surface of the colon is covered with coagulable 
lymph, which, in some cases, forms a chief part of the dejections. 
Here is a preparation which exhibits extensive sloughing of the 
mucous membrane; its tissue, you see, is quite abraded and 
destroyed. Here is a preparation of chronic dysentery, which pre- 
sents a very curious appearance ; the mucous membrane is finely 
mamillated, as it were, and it is stated on the label that the process 
of cicatrization was going on. It you compare it with the others, 
you will find a remarkable difference. Here is another specimen 
of dysenteric destruction. 

Here, then, is a disease in which we have violent inflammation 
of the mucous membrane and submucous cellular tissue, and, in 
severe cases, 1 believe, of all the coats of the great intestine, except 
the serous. Let us rehearse its symptoms briefly. Fever of an in- 
flammatory or typhoid character, great pain and excessive irrita- 
bility of the great intestine, morbid discharges of purulent, bloody, and 
lymphy matter, twisting pains called tormina, and frequently the 
absence of faecal matter in the dejections. 

At my next lecture I hope I shall be able to finish this subject, 
and I shall then bring before you some remarks on constipation 
and collections of air in the great intestine, two points upon which 
much light has been lately thrown. 



112 



STOKES'S THEORY AND PRACTICE. 



LECTURE XI. 

Sporadic dysentery — Nature of this disease — Treatment ; mercurial, stimulating, anti- 
phlogistic — Recommendation of Dr. Elliotson — Success of Dr. O'Beirne in the use of 
tobacco injections — [Salivation not a necessary measure of the therapeutic effects of 
mercury in dysentery — Calomel in full doses early in the disease — Opiates when 
required — The form of disease requiring tonics — Gastric complications — Ipecacuanha 
in large doses without vomiting — Opium advised by some in large doses from the 
beginning — Rectal dysentery — Its treatment] — Tympanitis, or meteorism — Windy 
colic, remedies for the cure of — [Notes on flatulent colic, bilious colic, inflammation 
of the caBcum and tuphlo-enteritis.] 

I dr£w your attention briefly, in my last lecture, to the subject of 
dysentery ; I stated that its anatomical character is now known to 
be inflammation of the great intestine, and gave it as my opinion, 
that, in many cases of the epidemic, disease of the large intestine 
occurs under one of two conditions, either as secondary to typhus 
fever, or with an extension of the inflammatory process into the 
small intestine. These circumstances should, I think, be always 
taken into consideration in cases of epidemic dysentery ; but the 
ordinary sporadic dysentery of this country, which we have now 
to consider, is, generally speaking, an inflammation of the large 
intestine.- The old doctrine -on this subject was, that dysentery 
was the result of an irritation caused by the presence of scybalae 
in the colon; and the indication was to attempt their removal by 
purgatives. You will find this opinion put forward in many of the 
older authors, and that the plan of treatment which they recom- 
mend is in perfect accordance with their notions of the disease. Jt 
is a very curious fact, however, that in this country these hard 
faecal masses, or scybalse, are very seldom met with in cases of 
dysentery. During the epidemic of dysentery, which occurred in 
Ireland in 1818, a series of clinical investigations was made on an 
extensive scale by Dr. Cheyne, who at that period had charge of 
the Hardwicke Hospital ; and he states, that on a strict examina- 
tion of the discharges in a vast number of cases, no scybalae could 
be discovered ; and in the sporadic cases, which we receive from 
time to time into the Meath Hospital, I have never found that the 
patients passed them. It is a great error to think that dysentery 
depends on the presence of scybalae ; the notion is now shown to 
be founded on a false pathology, and the treatment which it incul- 
cates decidedly bad. You will be convinced of the latter when 
you recollect that the disease is inflammation of the great intestine, 
that its effect is to throw the muscular fibres of the gut into violent 
and painful contractions, and that the existing mischief must be 
therefore greatly increased by the exhibition of strong purgatives. 
For a knowedge of the true and scientific treatment of this disease, 
we are indebted 4o the light which modern pathology has shed 
upon practical medicine. We now employ purgatives with extreme 
caution, we use general or local bleeding, according to the urgency 



SPORADIC DYSENTERY. 



113 



of the case ; and we treat the disease as an inflammatory affection 
of the lower intestine demanding active depletion. All writers are 
unanimous in recommending the employment of the lancet, in cases 
of acute inflammation ; and acute dysentery is one of those cases in 
which general bleeding seems to have the best effect. Dr. Cheyne 
states, that in this disease the most decided relief result from the 
use of the lancet. He says that in several cases in which there 
were excessive pain and tormina, and in which nothing was passed 
for several days but mucus and blood, as soon as venesection had 
been performed, the patients became comparatively easy, and 
passed large quantities of feculent matter. He also found that the 
blood drawn was buffed and cupped; and states that his experience 
led him to conclude that this disease was best treated by the lancet. 
Dr. Mackintosh, who has had great experience in dysentery, says, 
that laxatives will act with the best effects when blood-letting has 
been premised. In fact, the utility of general bleeding in dysentery 
is established beyond any possibility of doubt ; and those who 
object to the use of the lancet object to it on theoretical and not 
on practical grounds. As a proof of this, you will see a great 
many cases in which decided relief is obtained by a natural he- 
morrhage from the bowels ; and this I think ought to be sufficient 
to overcome the doubts of those who are skeptical as to the value 
of general bleeding in acute dysentery. 

Next to bleeding, the best thing you can have recourse to is the 
free application of leeches, a practice not sufficiently appreciated or 
followed in this country. I would advise you to apply leeches 
freely along the course of the colon ; and if the tenesmus be con- 
stant and distressing, round the anus also. The case in which the 
application of leeches round the anus is attended with the greatest 
relief, is that in which the tormina and tenesmus are excessive, and 
in which a quantity of blood is found blended with each discharge. 
After you have applied the leeches, I would strongly recommend 
you to direct your patient to sit in a hip bath for some time, and 
you will find that he will experience great relief, because the bath 
will act as a fomentation, and promote the flow of blood from the 
leech bites. I have often seen the application of a dozen leeches 
round the anus, followed by the hip bath, attended with the most 
rapid and signal advantage in dysentery. 

Many persons are in the habit of giving small doses of some 
mild saline laxative in this affection ; of this practice I cannot 
speak much from experience, and I think more benefit will be 
derived from the free use of demulcents, gum-water, whey, barley- 
water, and linseed tea.* But the internal remedies on which we 
chiefly rely in the treatment of dysentery, are mercury and opium. 
Blue pill and Dover's powder are an excellent combination, so are 
calomel and opium, and you may give either of these remedies 

* [Saline purgatives, so far from giving relief in some cases, are decidedly 
irritating ; they cause serous discharges, but not proper defecation. Alone 1 have 
found them of no benefit; following calomel, they answer a better purpose. — B.] 

11 



114 STOKES'S THEORY AND PRACTICE. 

alternately with a mild laxative, whenever you are led to suspect 
an accumulation of faecal matter in the bowels. In very bad cases 
it will be necessary to continue the mercury until the mouth is 
affected ; but in the sporadic dysentery of this country you will 
very seldom be under the necessity of bringing on actual sali- 
vation. 

Permit me here, gentlemen, to make a few observations on 
mercurial action. In treating a case of dysentery, it does not, in 
the first place, follow as a matter of course that you will cure your 
patient by subjecting him to the full influence of mercury. You 
are not to expect that salivation will be always attended with suc- 
cess. There is another point which should never be forgotten, 
although it is one which I believe has not been sufficiently consi- 
dered. It is a common idea with respect to the administration of 
mercury in cases of local inflammation, that if you produce saliva- 
tion you do a great deal towards accomplishing a cure, and this 
is true in most cases. Many persons are of opinion that it is the 
ptyalism which carries off the disease, and hence it is that we so 
often see the principal share of a practitioner's attention directed to 
produce salivation at all hazards. This is the history of the 
medical treatment ordinarily pursued in warm climates, where 
such vast quantities of calomel are given. Here the idea seems to 
be, that the disease is to be subdued by salivation alone, and 
accordingly the practitioner " throws in 5 ' mercury, an expression 
evidently arising from the enormous quantities given. There are 
many cases on record in which eight hundred and even one thou- 
sand grains have been given for' the cure of a single local inflam- 
mation. But it is remarkable, that in several cases in which vast 
doses have been given, no ptyalism has been produced, and thus 
it frequently happens, that the practitioner goes on increasing the 
quantity, lest he should have failed in consequence of not having 
given enough. All this practice is wrong and founded on false 
notions ; and I think that when you come to practice yourselves, 
you will be inclined to adopt the opinion, that, in cases in which 
mercury has been employed in the treatment of local inflammation, 
salivation is to be looked upon more as the result of the relief of the 
inflammation to a certain degree than as its primary cause. For 
instance, suppose you are called to treat a case of acute enteritis or 
hepatitis ; you give ten grains of calomel two or three times a 
day, and find that day after day passes without any appearance 
of salivation. Another practitioner is called in, who bleeds the 
patient, and this is almost immediately followed by the appearance 
of salivation and relief. My friend, Staff-Surgeon Marshall, who 
is intimately conversant with the diseases of India, has informed 
me that he has never known a case in which abscess actually 
formed in the substance of the liver, in which salivation could be 
produced ; and that when the patient became salivated, be believed 
it to be a proof that there was no inflammation of an intense cha- 
racter, or that no abscess had formed. The greater the intensity 



SPORADIC DYSENTERY. 



115 



of the disease, the less was the chance of salivation occurring, so 
that the salivation in certain cases appears to be the result of the 
same influence which produces a relief of inflammation, and not 
the cause of that relief. When, therefore, you have given mer- 
cury in free and repeated doses for twenty-four or forty-eight 
hours, and find no sign of salivation appearing, you should be 
cautious how you proceed, because in such cases the inflammation 
may be of that intense character which will not permit the mouth 
to be affected. Under such circumstances, the use of mercury, if 
rashly persevered in, will only aggravate the disease. In many 
cases of intense pneumonia, you will find that the patient will not 
be salivated until an advanced period, when, in consequence of the 
subsidence of intense irritation, the mercury is, as it were, allowed 
to produce its effect on the salivary glands. You may also fre- 
quently observe instances of intervals between the salivation, in 
which, during the course of an inflammation, the patient's mouth 
becomes affected by mercury : but if he gets fresh symptoms of the 
original affection the salivation disappears, and returns only when 
the new attack has been overcome by appropriate treatment. I 
think that, under these circumstances, we are authorized in consi- 
dering salivation as the effect of a certain degree of reduction of 
inflammation, and not as its cause. You will see the importance 
of these observations when you reflect in how many cases of local 
inflammation practitioners are in the habit of trusting to calomel 
alone ; not being aware of the fact, that inflammation of an intense 
character has a powerful tendency to prevent it from acting on the 
salivary glands. Be assured of this, that if, in any acute visceral 
inflammation, after you have performed the usual depletions, you 
find an unusual resistance to the action of mercury, you may, on 
that account, form a more unfavourable prognosis. 

There is one point in the treatment of dysentery which it is 
necessary you should be acquainted with. Sometimes the symp- 
toms steal on gradually, and the patient appears to be in a condi- 
tion not at all dangerous, when, all at once, the disease explodes 
with violence, and exhibits an extraordinary intensity ; the fever 
is ardent, the tormina excruciating, the tenesmus constant and 
harassing, the dejections frequent and blended with lymph and 
blood. Such an array of threatening symptoms must be met with 
a corresponding activity. In such a case as this I would bleed, 
leech, use the hip bath, and give free doses of calomel and opium ; 
and if you were to ask me to which of the internal remedies 
used I should attribute the most decided alleviating influence, 
I should say to the opium. Dr. Cheyne says, " after the lancet, 
the best remedy I know of is opium. " He says further: if another 
epidemic, similar to that which he witnessed, occurred, he would 
have no hesitation in giving opium, in four-grain doses, in such 
cases. 

There was a very curious circumstance connected with the his- 
tory of the epidemic dysentery of 1818-19. At one time the deaths 



116 



STOKES'S THEORY AND PRACTICE. 



happened to be extremely numerous, and everything which the 
experience or ingenuity of Dr. Cheyne could suggest failed in 
arresting the disease, in many cases. An English physician, who 
happened to be in Dublin at that period, and was in the habit of 
visiting the hospital, proposed the administration of large doses of 
cream of tartar, stating that he had tried it on several occasions 
under similar circumstances, and was convinced of its value. As 
the cases were not succeeding which had been treated after any of 
the ordinary modes, Dr. Cheyne consented to the exhibition of the 
cream of tartar, and allowed the physician to prescribe and ad- 
minister it himself. Accordingly, he proceeded to give it in doses 
of half an ounce every fourth hour. Its first effect, generally, was 
to produce violent distress, and to aggravate all the symptoms, but, 
after three or four doses, bilious and feculent stools came away, 
and the patient experienced the most extraordinary relief. Many 
cases which had been considered desperate improved and reco- 
vered, and Dr. Cheyne expresses his conviction that many persons 
were saved by this practice, who would have been lost under the 
ordinary modes of treatment. One of the old German authors has 
also alluded to this singular efficacy of cream of tartar in the treat- 
ment of dysentery ; and from the result of Dr. Cheyne's experi- 
ments, there can be no doubt that it is entitled to a high rank among 
the remedies usually employed. In case you should prescribe 
castor oil as a laxative, it will be necessary to combine it with 
mucilage of gum arabic and a few drops of laudanum ; given alone 
it will be likely to prove too irritating, particularly during the acute 
stage. In the advanced stage much benefit will be derived from a 
combination of castor oil, with tincture of opium and a small quan- 
tity of oil of turpentine. This is not at variance with the pathology 
of the disease, for there is a period in this as well as in every other 
form of inflammation, when stimulants may be used with benefit. 

Such is the treatment of the ordinary forms of acute dysentery, 
but it may happen that you will be cailed to a case in which you 
cannot employ these decided measures; and here J shall mention, 
that in all local inflammations it is of the utmost importance that 
you should act with judgment^and decision in the commencement. 
Every hour is precious; a single day is worth much ; and if two 
or three days are allowed to pass, and the treatment is inactive or 
indecisive, the patient too often sinks into the chronic stage, or dies. 
Whenever you happen to be called to treat a case of acute local 
inflammation, attempt to cut it short as soon as possible ; it is 
much easier to cure an inflammatory attack in its commencement 
than to save the patient from the effects of it in the advanced stage. 
Now, if you should be called to a case of dysentery of some stand- 
ing, and on your arrival find the patient lying on his back, his 
skin of a pale dirty hue, his eyes sunk and without lustre, his 
extremities cool, and bedewed with a clammy sweat, his pulse 
small, rapid, and feeble; his thirst ardent ; his pains and tormina 
incessant ; and constantly passing from his bowels a quantity of 



SPORADIC DYSENTERY. 



117 



fluid matter, blended with depraved mucus, lymph, and blood, with 
great irritation about the anus, and if these symptoms have lasted 
for some days, you may be sure there is extensive ulceration of the 
lining membrane of the large intestine. How are you to act under 
such circumstances 1 The patient will not bear bleeding, nor per- 
haps the application of a small number of leeches. Here your sole 
object must be to support your patient's strength; you must give 
wine, (if the skin be cool,) strong chicken broth, beef tea, jellies, &c. ; 
you must wrap your patient in flannel, and have recourse imme- 
diately to anodyne and astringent injections, and you should blister 
the abdomen, taking care to remove the blister at a proper time, 
and not leave it on so long as may add to the existing irritation. 
You may also prescribe the acetate of lead, or the sulphate of zinc 
with tincture of opium. I have seen several cases of this kind in 
the Meath Hospital, in which the administration of the sulphate of 
zinc was attended with good effects. The best mode of using it is 
to dissolve ten or twelve grains of the sulphate of zinc in six or 
eight ounces of cinnamon water, with a proportion of laudanum, 
and direct this quantity to be taken during the twenty-four hours. 
Dr. Elliotson recommends the sulphate of copper, and you can 
employ it in combination with opium. In this way, by supporting 
your patient's strength, keeping him warm, paying attention to the 
state of his bowels, using counter-irritation, and prescribing astrin- 
gents combined with opiates, (taking care not to check the discharge 
too suddenly,) you will often succeed, even in very bad cases. 
Before I quit this subject I may observe, that Dr. O'Beirne has 
succeeded in some cases, and in others has given great relief by the 
use of tobacco injections. You can understand this when you 
reflect that tobacco acts powerfully on the general system, and pro- 
duces effects somewhat analogous to bleeding. Like general bleed- 
ing it brings on faintness, vomitings cold skin, perspirations, and 
feeble pulse. It is also a powerful antispasmodic, and Dr. O'Bierne 
states, that its employment has been attended with the best effects 
in several very bad cases. I have not tried this remedy myself, 
but I think it well worthy of a trial in the acute stage of dysentery, 
when there is room for an antiphlogistic treatment. In the ad- 
vanced stages, of course, it is inadmissible. 

[ADDITIONAL REMARKS ON THE TREATMENT OF DYSENTERY. 

Before dismissing the subject of dysentery, it may not bethought 
out of place for me to fill up to a certain extent the outlines so 
ably sketched by Dr. Stokes in the preceding pages: and first, 
respecting the operation and effects of mercury in this disease. 

It is mere empiricism to look to salivation, either as a necessary 
proof that enough of mercury has been administered, or as an in- 
dispensable means of curing the disease. Salivation is an occa- 
sional result to be deprecated and avoided rather than sought for. 
After venesection and leeching, or where the inflammation is less 

11* 



118 



STOKES'S THEORY AND PRACTICE. 



intense, after leeching alone, I give calomel, in a dose of from ten to 
twenty grains, at once, or in a dose of five grains, repeated two or 
three times at an interval of three hours, until the lower bowels 
are relieved by a discharge of retained scybala and fecal matter 
mixed with bile and mucus. If the medicine fails to operate 
freely in this way in from twelve to sixteen hours, we should ad- 
minister some of the milder purgatives, such as rhubarb and mag- 
nesia, salts and magnesia, compound powder of jalap, or castor-oil. 
If there be much nausea and distress of stomach, we may be con- 
tent to aid the operation of the calomel by enemata. Again and 
again I have seen the most complete relief from all the troublesome 
symptoms of dysentery — tenesmus, mucous and bloody discharges 
from the rectum, fever, and the indescribable painful sensations 
which follow irritation of the large intestine — after one or two 
copious evacuations as above, procured by the calomel. Sometimes 
this relief is but temporary; and the pain, and straining at stool, 
fever, and foul and even dried tongue, harsh and hot skin of 
the abdomen, and coldness of the extremities, show that the disease 
persists in its course. Leeches over the region of the colon, and, 
notably, corresponding with its arch, or to the anus, will again be 
advisable here ; and calomel in smaller doses, say one to two grains 
every three hours mixed with a little gum arabic, will be useful, 
by acting on the mucous surface and muciparous glands of the 
intestines, restoring their healthy secretion, and that also of 
bile which is suspended, or this fluid is retained in the small "in- 
testines, and does not enter the coIoh. If the calomel fail to 
answer our expectations in this way, we ought not blindly to per- 
severe in its use, with a view of inducing salivation. On the con- 
trary, we ought to desist from its administration, and either abstain 
from active medication for a while, content to direct demulcent 
drinks and mucilaginous enemata, warm pediluvium, perhaps a few 
leeches, and if fever persist, minute doses of tartar emetic com- 
bined with opium. I prefer giving calomel alone, in the earlier 
stage of dysentery, to its combination with ipecacuanha, or 
with ipecacuanha and opium, from a belief that the former of these 
two medicines rather interferes with, than aids the salutary action 
of the calomel ; and that it is directed under the influence, very 
much, of the old pathology of dysentery, in which the disease was 
regarded as one of weakness marked by excessive morbid dis- 
charge from the bowels, which ipecacuanha had the power of 
checking. I do not think that we are prepared to speak in posi- 
tive terms of the real effects, either direct or remote, of the com- 
bination of opium and ipecacuanha with calomel in the early or 
inflammatory stage of dysentery; and, until w T ehave definite notions 
of the operation of a compound, we had better content ourselves 
with the articles singly of which it consists, when they have, each 
of them, admitted power. In succession or alternation, we can 
generally procure all the salutary results derived from the adminis- 
tration of several medicines at once. Thus, after calomel has ex- 



SPORADIC DYSENTERY. 



119 



erted its efforts in the manner already mentioned, if there is still 
diarrhoea with little or no tenesmus or tormina, ipecacuanha 
with chalk or carbonate of magnesia will advantageously come 
into play. At this time, also, as the skin will commonly be found to 
be dry, and there is restlessness and general irritation preventing 
sleep, opium will answer a good end. Taking it as a basis, we can 
add ipecacuanha to it, as in Dover's powder ; or, substitute for the 
neutral salt in this latter, chalk or carbonated magnesia. We may 
at the outset, or at least so soon as we think it advisable to give 
calomel in dysentery, combine a little opium with it ; with a 
view of making it rest more tranquilly on the stomach, and of dimi- 
nishing its sickening effects in its passage through the small 
intestines : but to the frequent routine use of calomel and 
opium, from the beginning, in dysentery, I am opposed, for the 
reason, in addition to that already given, that opium is generally 
prejudicial in the beginning of the disease, and thus interferes with 
in place of aiding the operation of the calomel. The best prepara- 
tion for the latter is venesection and leeches : the best adjuvants, 
diluent and demulcent drinks, simple enemata, and fomentations. 
Camphor water, mint water, or mint or peppermint teas, may, on 
occasions, be used at the same time, with the effect of tempo- 
rarily allaying pain and soothing, until more complete and perma- 
nent relief is obtained by the calomel ; but the appropriate drinks for 
common and continued use through the course of the disease, are 
rice, barley, gum water, and occasionally a little well-boiled thin 
gruel. 

A cold and dry skin, diarrhoea in place of tenesmus and tormina, 
or the occasional recurrence only of these; pulse frequent, but without 
force ; a tongue which has lost its redness and is less loaded, will indi- 
cate the propriety of the administration of Dover's powder, with 
warm herb teas, the warm bath or warm pediluvia, or stimulating 
liniments to the abdomen. As regards the use of turpentine, the 
reader will get the requisite information in the text. A combination 
of opium or laudanum in camphor water, with mucilage of gum 
arabic, and the addition of a few drops of nitrous or nitric acid, 
known for some time as Hope's Mixture, is a favourite prescrip- 
tion with some practitioners. I have often employed it, but without 
anything like the uniformity of pleasant results which its more san- 
guine friends claim for it. 

This sketch of the treatment of dysentery is more directly appli- 
cable to the sporadic cases which I have been accustomed to see 
in Philadelphia, in the early partof the summer, and also to those met 
with in the same season in the country, and more particularly in 
the lime-stone regions of Pennsylvania and Virginia. In these last- 
mentioned districts it may, to a certain extent, be considered 
endemial. 

In the autumnal dysentery, and that which prevails in low lands 
at the same time with intermittent fever, there is not the same 
urgency for the use of the lancet as in the variety already described. 



120 



STOKES'S THEORY AND PRACTICE. 



Leeches to the abdomen, or even a few cups where the former are 
not readily obtained, will take the place of the lancet. Recourse 
also will be had more freely to quinine, and greater stress laid on 
counter-irritation by blisters and tartar-emetic ointment ; not so 
much with a view of acting on the colon as for the relief of the 
liver and spleen, engorgements and chronic inflammation of which 
are not unfrequent accompaniments of the disease. The use of calo- 
mel will be of shorter duration, and will be followed by the earlier 
administration of ipecacuanha and opium, than in the more acute 
and inflammatory dysentery of summer. The variety under con- 
sideration most commonly ends in chronic diarrhoea, which taxes 
the ingenuity of the practitioner in the selection of various astrin- 
gent medicines. Without denying the utility of these, I can speak 
with more confidence of the advantages to be obtained from the use 
of the blue mass in doses of two or three grains night and morning, 
and mucilaginous drinks — the food to consist of rice well boiled, 
arrow root, &c, with the addition, if they do not prove too oppressive 
to the stomach, of milk and cream. I learned, now many years ago, 
the practice of using the blue pill in this stage of dysentery from 
Mr. Pearson, the estimable surgeon of the English Factory at Can- 
ton, and have had continued reason to be pleased with the remedy 
ever since. In simple profluvia, after the subsidence of inflamma- 
tory irritation, as well as in hemorrhage from the bowels, and me- 
norrhagia of a chronic kind, I have employed tannin, in doses 
of three to five grains twice or thrice a day, according to the 
exigency of the case. 

Although the anatomical lesion characteristic of dysentery, on 
which the chief symptoms and progress of the disease depend, is in- 
flammation and ulceration of the mucous follicles and intermediate 
membrane of the colon and rectum, and occasionally of the lower 
part of the ileum, there have been fatal cases in which no organic 
change of this nature was obvious. At times, and not unfrequently, 
especially at the commencement of dysentery, the gastric symp- 
toms predominate ; a modification set forth in a strong light with 
his accustomed ability by Dr. Chapman. Under such circum- 
stances, our attention should be at first mainly directed to the sto- 
mach, and suitable means had recourse to in order to allay its 
irritation. With this view, leeches over the epigastrium, laxative 
enemata, cool demulcent drinks, will be a proper prelude to ulterior 
treatment, which in this case will be singularly simplified and 
easier. Frequent nausea and retching, or a bitter taste in the 
mouth, and the known presence of indigestible matters in the 
stomach and upper bowels, would seem to indicate the propriety of 
administering an emetic ; and, accordingly, vomiting has been often 
had recourse to as a remedy in dysentery. That it is sometimes 
useful in the beginning of the disease I know well from repeated 
experience; but the same cannot be said of it in a more advanced 
stage, when the tongue is dry and furred and the abdomen hot and 
tender, and other symptoms point out phlogosis of the intestine. The 



SPORADIC DYSENTERY. 



121 



emetic to which preference is commonly given is ipecacuanha, but, 
as 1 cannot help thinking, on speculative grounds. Thus, it was 
| supposed to have the double action of an emetic and an astringent, 
j and as such thought to be peculiarly adapted to dysentery. But 
> admitting this double property, which by the way is not proved, it 
j does not by any means follow that the first stage of sporadic 
j dysentery is the time for its salutary manifestation. Whether we 
; have regard to the inflammatory state of the large intestine, or to 
j the febrile disturbances in consequence, preference ought to be 
I given to a remedy which has a direct and well marked effect in 
| reducing if not removing these phenomena ; and this remedy is the 
; tartar emetic. There is every indication for this latter, and none 
| for the astringency of the ipecacuanha. Some persons would cut 
1 short all reasonings as to its modus operandi, and claim now for 
I ipecacuanha the same credit which it enjoyed when introduced 
into general practice by the first Helvetius, viz. : the power of 
| exerting a direct and specific action on the diseased organs. 

Without formally announcing a proposition of this nature, the late 
I Mr. Twining of Calcutta seems to have acted on the idea involved 
in it, by recommending large doses of ipecacuanha in dysentery 
| without exciting vomiting. Having cleansed out the bowels by a 
dose of castor oil, he gave six grains of ipecacuanha, with four 
grains of extract of gentian, and five grains of blue mass in three 
pills, which were repeated every night at bed-time, and at day- 
i light in the morning a small dose of compound powder of jalap* 
A cessation of all the distressing symptoms ensued, and it was 
sufficient to continue six grains of ipecacuanha, with four grains of 
gentian every night, and to give a very small dose of compound 
powder of jalap, or a moderate dose of oil every morning for four 
or five days more. Mr. Twining says, that ipecacuanha seldom 
produces vomiting, and that he has often given twelve grains of 
this article with eight grains of extract of gentian in four pills 
without exciting vomiting; and half this quantity to a young per- 
son, thirteen years of age, without causing nausea. The power of 
the gentian to control the emetic effects of the ipecacuanha seems 
to be evident from the fact, that three grains of the latter of the 
same parcel and bottle, given alone, repeatedly vomited. Accord- 
ing to Mr. T. the first effect of ipecacuanha, given in ordinary 
cases of acute dysentery, is for the most part generally, a slightly 
increased intestinal secretion, the evacuations becoming more 
copious and feculent — pain and tenesmus are abated, while the 
i quantity of blood and slime immediately decrease, and soon disap- 
, pear altogether. It will be seen, at once, that this practice is not by 
any means conclusive of the operation and effects of ipecacuanha, 
so much as of the prescriptions of Mr. Twining, into the composi- 
tion of which it is true this latter medicine enters in large propor- 
tion. 

We can repose the more confidence in the accuracy of Mr. 
Twining's description of the results of what some would term the 



122 



STOKES'S THEORY AND PRACTICE. 



ipecacuanha practice, from the fact that he wasnot by any means 
exclusive in his views, nor wedded to one particular remedy. Thus 
he says : At the same time I most strenuously urge the necessity 
of a free use of the lancet, and repeated bleeding by leeches in all 
recent cases of dysentery, where there is either pyrexia, morbid 
sensibility of the belly on pressure, evacuation of blood with the 
stools or tenesmus. But when repeated bleedings have accom- 
plished all that can be wished from them, ipecacuanha, with the 
medicines above stated, will be found of infinite service in soothing 
irritability and restoring a healthy state of the bowels. " I need not 
say," continues Mr. T., " that tepid baths, fomentations, and poultices, 
over leech bites while they are still bleeding, are useful. Where 
the free use of calomel has been chiefly relied on and employed to 
salivate, in some instances a purging and tenesmus have still con- 
tinued, and in these the combination of ipecacuanha and gentian 
has then been employed with the most happy results. Opiates 
have generally appeared injurious in dysentery, except when given 
with calomel, so as to cause that medicine to be retained in the 
first portion of the intestines, while it may act on the secretions of 
the duodenum and liver." 

As Mr. Twining practised in Calcutta, his opinions and descriptions 
are applicable of course to East India dysentery, and on this ac- 
count I have the more freely transcribed them for the benefit of the 
practitioners of the southern portion of the United States, who may 
be expected to regard him as authority of more weight than a 
writer at home, one resident in the northern states. 

The partiality for large doses of ipecacuanha in dysentery was 
manifested long before Mr. Twining's time. Reference to a com- 
munication by Mr. Balmain, in the fourth volume of the Memoirs 
of the Medical Society of London, will show us that this gentleman 
gave repeatedly two drachms at a dose, with the addition, however, 
of sixty drops of laudanum. In many cases, he tells us, that a dose 
or two w r as sufficient to remove every dangerous symptom. The 
ipecacuanha answered the purpose best when given in the form of 
pills ; and, adds the narrator, " if the patient kept still and lay on his 
back, with the head and chest tolerably elevated, nausea seldom or 
ever followed it ; and oftentimes it happened that he had not a stool 
the succeeding day, although previously the gripings were violent, 
and the discharges of blood frequent and in large quantities." 

I ought not to conclude these somewhat desultory remarks on 
the treatment of dysentery without specific allusion to the use of 
opium in large doses, from an early day, in this disease. Broussais, 
Cheyne, Christison, and other names of high authority, are adduced 
in its favour. Dr. Cheyne's opinion has been given in the text; and 
Dr. Christison, in the treatment of the cases of epidemic dysentery 
which came under his charge above ten years ago in the Edinburgh 
Infirmary, found opium to give the greatest relief, after the stage 
in which feculent matter was discharged and had ceased, and the 
evacuations had become muco-sanguinolent, or sero-sanguinolent. 



SPORADIC DYSENTERY. 



123 



1 At this time he commonly directed the application of leeches to be 
! immediately followed by doses of pure opium, of such magnitude 
I and frequency as were found necessary to check the unremitting 
diarrhoea and tormina ; and sometimes the desired effect was not 
procured until the patient was pretty strongly affected by the 
narcotic action of the drug. In urgent cases, twenty or twenty- 
| four grains were sometimes necessary from the very beginning ; 
| in the slighter cases, four or six grains were sufficient. " When an 
| impression was once made on the discharges, it was maintained by 
i doses of two or three grains repeated according to circumstances, 
, and frequently the exhibition of opium by the mouth was conjoined 
! with its employment 'in the form of suppository." But it would 
j appear from the sequence of Dr. Christison's narrative, that the 
I opium was more palliative than decidedly curative in its operation, 
I for he speaks of the blood reappearing abundantly in the stools, 
"if the opium was intermitted on account of its causing too com- 
, plete constipation." And again : " After the hemorrhage was perma- 
I nently checked, the frequent, thin, feculent, stools continued many 
! days, sometimes many weeks, indicating, it is to be presumed, the 
existence of ulceration, which consequently must have taken place 
at a very early period of the disease" 

In autumnal dysentery, in that alternating with rheumatism, or 
in which the symptoms indicate a predominance of neuralgia over 
phlogosis, in cases of cold skin and feeble action, and in the begin- 
ning of more acute cases before reaction, and when the skin and 
; extremities are still cold, opium in a full dose of two or three grains, 
with warm drinks, may be given with advantage. But if the in- 
flammatory action has been fully developed in the mucous follicles 
and membrane, this medicine will poorly meet our wishes by 
merely deadening sensibility, and simply suspending for a while the 
morbid processes, which, if not more completely checked, will end in 
ulceration and gangrene. Dr. Miner, of Connecticut, who is an 
advocate for the opium practice, lays great stress on the benefits of 
a union with it of capsicum. His prescription is a pill consisting 
of one grain of capsicum and opium each, every two hours— but 
for how long a period he»does not state. Of the utility, and exceed- 
ing comfort, by the removal of tormina and tenesmus, from the use 
of opium by enema, there can be no doubt ; but even this mode of 
administration is not adapted to every stage of dysentery, but rather 
to the second, in which there is an abatement of fever and inflam- 
mation, and in which it becomes necessary to procure, if possible, 
tranquillity and sleep for the patient during even a few hours. The 
| chances of retention of the enema will be, of course, in proportion 
I to the smallness of the quantity and the mildness of the vehicle — 
! warm mucilage, or even simple water. 

There are cases in which the disease is confined almost entirely 
to the rectum, which is inflamed, and discharges blood and some 
mucus, and is thrown into a spasm at each effort of defecation. 
Here, although there is often much sympathetic distress — headache, 



124 STOKES'S THEORY AND PRACTICE. 

fever, full pulse, with thirst and restlessness — the remedies required 
are merely topical, viz., leeches to the anus, emollient and narcotic 
enemata, and afterwards a weak solution of the acetate of lead, and 
still later of sulphate of zinc. After the subsidence of the rectal in- 
flammation the bowels may be acted on by a dose of calomel, fol- 
lowed by castor oil mixture, which will discharge scybala and 
bile, and give the patient entire ease. — B.] 

We come now to consider the affection of the digestive tube, 
which merits a separate consideration, and this is tympanitis, or, as 
it is sometimes termed, meteorism. I shall not enter upon the ge- 
neral pathology of aeriform effusions into the abdomen ; we are not 
acquainted with that peculiar condition of parts which produces 
them, but it is now established that we may have effusions of air, 
not only into the digestive tube, but also into every part of the 
body. The term tympanitis is limited to effusion of air into the 
digestive tube, in all parts of which we may find it. We detect it 
in the stomach under two circumstances ; first, as a recent and 
transient affection, as when it comes on after swallowing indigesti- 
ble matter ; secondly, in a more permanent form, as when it depends 
upon hysteria, hypochondriasis, or chronic gastritis. It may be 
also frequently seen in very young children, when there is fever- 
ishness with irritation of the digestive system. I recollect a very 
remarkable case of this kind, in which the distension was so great, 
and the pressure on the diaphragm so considerable, as to cause 
displacement of the heart upwards ; — this, I believe, has not been 
mentioned among the causes of displacement of the heart. The 
symptoms of this affection are sufficiently obvious ; — a sense of 
uneasiness and distention at the region of the stomach ; when the 
effusion is in excess, a distinct tumour can be felt, and the sound 
on percussion, over the stomach, is like that of a drum. It often 
happens, also, that when the patient is shaken, a distinct sound of 
fluctuation is heard, a circumstance which more than once has 
led to the suspicion of the existence of pneumothorax, or empyema. 
There are also cases on record, in Which the distention was so great 
as to cause rupture of the stomach, and effusion of its contents into 
the cavity of the peritoneum, causing intense inflammation and 
rapid death. 

The effusion of air into the intestinal tube is extremely common 
in cases of acute enteric inflammation and gastro-enteritis, after the 
disease has lasted for a few days, and, as this is a matter of consi- 
derable interest, I wish to make a few remarks upon it. It is of 
importance that you should bear in mind that this is one of the 
results of enteric inflammation, because many persons are in the 
habit of looking upon it, not as a mere symptom of another affection, 
but as a peculiar form of disease, forgetting that it may occur with, 
as well as without, inflammation. In consequence of this limited 
and imperfect view of the subject, they are in the habit of prescribing 
turpentine as a specific remedy for tympanitis. Now, I can say 



SPORADIC DYSENTERY. 



125 



that I have seen the most dreadful effects from the administration 
of turpentine in the tympanitis of acute enteric inflammation. The 
immediate effect is to produce a rapid diminution of the tympanitic 
swelling ; but this is purchased at too dear a rate ; for you will find 
next day that there will be a violent exacerbation of the existing 
symptoms, and the tympanitis becomes worse than before. You 
should never, therefore, interfere in this w 7 ay with the tympanitis of 
acute enteric inflammation, nor should you alter your practice on 
this account in the slightest degree, except where the tympanitis is 
so great as to interfere with the due performance of the function of 
respiration ; but, in the advanced stage, after the twelfthor sixteen 
day, when the fever has abated and the tongue is moist, I have 
frequently seen great advantage result from the use of turpentine. 
But as long as the condition of your patient admits of antiphlogistic 
treatment, be assured that the administration of turpentine is hazard- 
ous. When the patient is in a low state, when you can no longer 
have recourse to bleeding or leeching, when the tympanitis is con- 
nected with an asthenic condition of the intestinal mucous membrane, 
then, and not till then, should you venture on the employment of 
turpentine. I shall return to this subject when we come to speak 
of hysteria. 

I may mention here, that the occurrence of flatus in the intestines 
sometimes gives rise to dreadful sufferings in that affection, which 
has been termed windy colic. A person in the enjoyment of good 
health happens to take at his dinner or supper a quantity of indi- 
gestible food, he goes to bed without feeling any particular incon- 
venience, but about the middle of the night he awakes with an 
attack of pain and tormina, which extend from the hypochondria to 
the umbilicus. This subsides for a short time, and then returns with 
violence, and the patient often finds that it is relieved by pressure. 
In a short time the pains get worse, and the abdomen begins to 
swell, sometimes at one point, sometimes at another, as if the air 
was confined and pent up in particular situations. The patient 
begins to suffer indescribable anguish, he has great anxiety, extreme 
prostration of strength, his face is pale, his extremities cold, a cold 
sweat breaks out all over the body, and he sits bent forwards, with 
his hands pressed on his stomach to relieve the paroxysms of pain 
which come on with increasing rapidity. In some cases there is 
distressing hiccup, in some a large quantity of aqueous urine is 
passed, in some there are loud borborygmi, and the intestines may 
become so enormously distended as to fall rapidly into a state of 
gangrene. Hippocrates has given a description of one of the forms 
of this disease, which terminates by the passage of air upwards and 
downwards, by which the patient obtains relief ; this he calls dry 
cholera. This windy colic is an exceedingly violent disease : one 
of the first cases of which I witnessed, presented such an array of 
alarming symptoms, that I thought every moment the patient would 
expire. It is, howeveV, a disease which is generally easily managed 
if taken in time. One of the first things to be done is to apply 

12 



126 



STOKES'S THEORY AND PRACTICE. 



heat to the abdomen by anodyne stupes, or warm flannel. Flannels 
wrung out of a decoction of poppyheads, as hot as can be borne, will 
do a great deal of service, and in some cases will give complete 
relief, when assisted by the use of carminative draughts. But of 
all the remedies which I have seen, the most efficacious is an injec- 
tion with tincture of asafoetida, turpentine, and opium. This is 
generally followed by speedy relief, the pulse becomes more natural, 
the belly soft, and the excruciating agony is relieved. This is the 
mode of treatment in which I have the greatest confidence. After 
the acute symptoms are removed, it will be proper to exhibit a 
laxative, for the purpose of removing the exciting cause of the 
disease— indigestible matter ; unless you get rid of this, your patient 
is liable to a return of the attack, and even to an inflammation of 
the tube itself. Be not, therefore, satisfied with merely relieving 
your patient; watch him carefully, and, by a proper treatment, 
obviate a recurrence of the symptoms, and prevent any tendency to 
inflammation. 

[notes on flatulent and bilious colic, and inflamma- 
tion OF THE CAECUM. 

The first case of colic which I saw, at a time when I was yet 
but a young student, and for which most unwillingly on my part 
I was requested to prescribe in the absence of my preceptor, gave 
me a lesson worth inculcating on the present occasion. It is, that 
the pain and distress felt in flatulent or windy colic depend, not 
unfrequently, on indigestible matters in the stomach, the evacuation 
of which is followed by a removal of all the distressing symptoms. 
My patient was a stout butcher, to whom I gave essence of pep- 
permint and mint tea, and hartshorn and laudanum, in succession, 
but without any immediate mitigation of his complaint, until, hap- 
pily, either owing to the irritation from the admixture of my pre- 
scriptions, or from that of the offending food in the stomach, he 
vomited up the latter, which had been eaten some hours before 
for dinner. The consequence of this evacuation was entire relief. 
Acting on this hint, I have occasionally since given either salt 
and water, or a few grains of ipecacuanha, with a view of 
emptying the stomach — a plan preferable to the more tedious one 
of first expelling flatus by carminatives, then allaying pain by an 
opiate, and finally emptying the bowels, either by an enema or pur- 
gative, or by both in succession, sinapism to the epigastrium, &c. 

In other cases, the sustaining cause of colic is really in the colon, 
and consists of hardened faeces retained in this canal, particularly 
in the cells. The effect is, sometimes flatulence and distention of 
the intestine, sometimes diarrhoea, consisting of serous discharges 
and a few scybala ; and the cure of which is to be found in large 
saline or asafoetida and turpentine enemata, and an active purga- 
tive, such as calomel and jalap, or, preferably, castor oil and tur- 
pentine. In tolerably thin subjects, we can assure ourselves of the 
nature and cause of the malady by feeling the indurated matter 
in the colon, particularly at its arch and in each iliac region. 



[BILIOUS COLIC] 



127 



On some occasions, whether from a spasm, which is part of the 
disease, or from other causes, there is an almost entire obstruc- 
tion in the lower portion of the colon or at its sigmoid flexure, by 
which neither wind nor faeces can be discharged downwards, nor 
enemata passed from the rectum upwards. In such a case, it is 
necessary to adapt a flexible tube of sufficient length to the pipe of 
an injecting syringe, and having carried the former gradually up 
the rectum, to beyond the spasmodically strictured part, to intro- 
duce through it the contents of the syringe. The speedy discharge 
both of flatus and faeces indicates, and at times proclaims, the effect 
j of the remedy and the cure of the disorder. Every now and then, 
| both in flatulent distention of the colon, and in tympanites itself, it 
j will be sufficient to introduce some way up the colon an elastic 
\ tube, such as a large catheter with its end cut off, or, still better, 
! the tube of a stomach pump, in order to procure the extrication of 
1 a large quantity of gas and great relief to the patient. 

It is the duty of a physician called to a case of colic which is not 
' soon removed by his remedies, and especially if it be accompanied 
i with retching or sickness of stomach and dragging at the epigas- 
trium, to institute careful inquiries, and make the requisite examina- 
i tions, in order that he may ascertain whether the symptoms do not 
i depend on strangulated hernia, either at the crural or abdominal 
j ring. If this displacement have actually occurred a diminution of 
I the distressing symptoms will be obtained, and the return of the 
! protruded gut greatly facilitated by the introduction of the rectal 
tube, as recommended by Dr. O'Beirne. Quite recently a case of 
strangulated scrotal hernia, of three days' duration, and irreducible 
by the taxis, is recorded in the London Lancet (February 1, 1840) 
to have been so much diminished in size by this means as to be 
readily reduced. The narrator and surgeon, Mr. Maunder, intro- 
duced the tube of a stomach pump twenty-six inches up the intes- 
tine, " and, after the expiration of about ten minutes, air escaped in 
small quantities from its mouth; the scrotal tumour gradually 
diminished, and the poor fellow was soon released from suffering, 
the sickness ceased, pain was diminished, and the dragging sensa- 
tion completely relieved." Two drops of croton oil with sugar, 
divided into three doses, one taken every three hours, and followed 
up by a little saline mixture, acted powerfully on the bowels and 
completed the cure. 

Bilious Colic, as far as my own observations extend, is a disease 

1 much more frequently met with in the country than in cities : at 

| least I saw more cases of it when a student in Virginia than I 

. have since met with either in private or public (Dispensary) 

i practice in Philadelphia. Bilious colic makes its attacks in the 

i great heats of summer, and is a precursor, on the score of time, as 

j it is sometimes more immediately in the same person, of bilious 

j fever. Some are more predisposed to the disease, so as to be 

' much more readily affected than others by the occasional exciting 



128 



STOKES'S THEORY AND PRACTICE. 



causes : — These- are excess in the quantity, and error in the quality 
of the food ; free potations of spirituous or ascescent liquors ; cold 
drinks, as of ice water or milk, especially if the stomach has been 
weakened by indulgence in the use of strong liquors ; hard 
labour or excessive exertion of any kind in a hot sun, and subse- 
quent exposure to the cool damp air of night, either by sleeping in 
the open air or under open windows indoors. A little difference, 
hardly appreciable, in the constitution of two individuals, and per- 
haps in the quality of the articles eaten at supper, will cause in 
the one bilious colic, in the other cholera morbus. 

Bilious colic is sometimes preceded by indigestion and slight 
febrile action : but often comes on suddenly in the night or at an 
early hour in the morning without other premonition than a slight 
chill. The symptoms are — irritability of the stomach and occa- 
sional vomiting of bilious matter ; pain in different parts of the 
intestinal canal and distention by flatus ; cramp of the abdominal 
muscles, which is soon participated in by the muscles of the limbs, 
especially the lower ones ; coldness of the surface, particularly of 
the hands and feet. After a short time, the skin of the abdomen 
is hot, the face is flushed, and there is some throbbing of the tem- 
poral arteries ; the pulse, at first small or not materially changed, 
is now frequent and hard with more volume; the tongue is loaded 
and of a yellowish hue. In a short time, together with the expres- 
sion of anxiety and suffering displayed in the face, the complexion 
is altered from its natural colour to a dingy-yellow hue, partially 
relieved in the stage of febrile reaction by a blush on the cheeks. 
The bowels are almost universally in a constipated state, a symptom 
this diagnostic of the disease from cholera morbus. Sometimes the 
vomiting is carried so far as to constitute the iliac passion. Numb- 
ness and tremors of the upper extremities are occasional symptoms. 

The anatomical lesions manifested in the bodies of those who 
have sunk under bilious colic are chiefly inflammation and inflam- 
matory congestion of various parts of the small intestine, particu- 
lar!} 7 at the duodenum and the ileum, and similar though less 
marked alterations in the stomach, and morbid ^accumulation of 
blood in the liver. If we connect these appearances with the 
symptoms sketched above, we can have no hesitation in regarding 
bilious colic as a true gastro-enteritis, with the occasional compli- 
cation of hepatic disorder. 

The treatment which I early became familiar with is the best 
adapted, if we except the too free use of purgatives, to the chief 
exigencies of most cases of the disease. It consisted in vene- 
section from sixteen to twenty-four ounces, the administra- 
tion of sixty to a hundred drops of laudanum, or three or four 
grains of opium, if the stomach was irritable, by the mouth; 
immersion in the water bath, or, in its stead, fomentations over 
the abdomen of cloths squeezed out of hot vinegar and water, 
and sinapisms to the legs and arms. Relief commonly procured 
by these means is rendered more abiding by large stimulat- 



[BILIOUS COLIC] 



129 



ing enemata, as of an infusion of senna with salts, castor oil with 
turpentine and: asafoetida, repeated until the bowels are freely 
evacuated, and at any rate until fecal matter ceases to be dis- 
charged. The recurrence of pain will be met by simple enemata 
of warm water, or by those of fluid in small bulk with which thirty 
to forty drops of laudanum have been mixed. 

Having by this active treatment procured a respite from suffer- 
ing, and a remission, in part, of the disease, the next point to be 
determined is how far and by what means the bowels should be 
acted on with a view to their complete evacuation. In the same 
school in which I was initiated into the early treatment of bilious 
colic I was taught the advantages of a full dose, say twelve to 
fifteen grains, of calomel at this time, — either alone, or if the sto- 
mach was still irritable, combined with two or three grains of 
opium. More commonly this prescription was made with a view 
to its administration preceding nearly all other remedies by the 
mouth, and in place of the laudanum or opium as before recommend- 
ed. I now prefer the simple course, — viz. : to obtain a cessation of all 
the symptoms by the treatment which I have laid down, and then to 
give a calomel pill in the dose just indicated. In prescribing this medi- 
cine at this time and in this dose I bear in mind, and indeed parti- 
cipate, in the strong dislike which the Broussais school entertain to 
drastic or irritating purges in gastro-enteritis. But I do not think 
that in my practice I am inconsistent with my theory. I believe 
calomel to be, when judiciously timed in its administration, one of 
the best remedies we have against phlegmasia of the digestive 
canal : at the same time it must be acknowledged that I am more 
persuaded of the fact than ready with an adequate explanation. 
The calomel now given in its passage downwards exerts a kindly 
operation on the duodenum and the ileum, and by its impression on 
the former being transmitted to the liver it acts on this organ, which 
is in consequence relieved from its temporary congestion and now 
secretes bile. The large intestine, obedient to the double stimulation 
of the bile brought to it from above and of the calomel, now dis- 
charges freely its contents, together with those which have been 
passed down from the small intestines ; and entire relief, manifested 
often in a tranquil sleep, is, soon after, enjoyed by the patient. It may 
be that the calomel is slow in its operation, or that, although it is the 
first and often the best medicine to tranquilize an irritable stomach, 
it now, just at the time of its passage through the ileo-ccecal valve, 
| causes sympathetic nausea and sickness. In either case we give 
! moderately stimulating enemata — often tepid water, with some com- 
mon salt dissolved in it, will answer — and repeated until there be 
! free evacuations. In desiring free evacuations in colic in all its 
I varieties, I am not merely influenced by the consideration of re- 
I moving irritating matter from the bowels, and diminishing excite- 
j ment by the discharges from the mucous surface, but also by that 
I of being assured that the regular peristaltic action is reestablished 
| in the entire course of the digestive canal. 

12* 



130 



STOKES'S THEORY AND PRACTICE. 



At this particular juncture it behoves the practitioner to be on 
the alert, and to ascertain, very positively, whether his patient is 
now clear of disease, and only requires rest and simple farinaceous 
diet for his restoration, or that it is merely in a state of remission. If 
the latter, he will expect to find the pulse somewhat hard, or slightly 
corded and frequent, and the abdomen still tender; not that dif- 
fused tenderness which any muscular part will evince after violent 
exertion, normal or spasmodic, but circumscribed to some portion, 
as the iliac region, or round the umbilicus. The tongue at the 
same time is dry and furred, and the thirst considerable. This is a 
critical period in the disease. If recourse be had now to drastic 
purgatives, or, from mistaken notions about debility, to tonics, 
the inflammation of the intestine is aggravated, the distress of the 
stomach increased, and the disease terminates rapidly and fatally. 
Equally to be dreaded is the ingestion of animal broths or stimu- 
lating drinks, sometimes allowed under the idea that the first remis- 
sion is the actual beginning of convalescence. If there be doubt 
about the real state of the digestive canal, the safer plan will be 
to abstain for a day or two from active medication, and certainly 
from animal food or diffusible stimuli, under which head I include 
vinous and distilled liquors, until the characteristic symptoms, one 
way or another, are more fully developed. But if the symptoms, 
as indicated at the beginning of this paragraph, are present, we 
should have recourse to the use of leeches, or if there be not too 
great tenderness of abdomen, to cups applied on the iliac region. 
If circumstances prevent recourse to either of these means of local 
abstraction of blood, we ought to endeavour to attain our end by 
venesection in small quantities, viz., six ounces at a time ; watching 
the effect, and repeating in twelve hours the operation, if the pain 
and tenderness of a portion of the abdomen corresponding with the 
ileum beneath seem to call for the measure. During this time 
we should abstain from irritating the bowels, either by active purging 
or by strong enemata. Tepid water thrown up by the rectum 
will answer every purpose in procuring regular evacuations. Anti- 
monials with opium, or Dover's powder, given at intervals of 
two or three hours throughout the twenty-four, contribute to re- 
move the inflammation and abate febrile action. Revulsion by 
blisters over the abdomen or to the lower limbs, and warm pedi- 
luvia, may next be used with advantage. 

Having sketched the course of treatment in bilious colic which 
my own experience induces me to believe correct, I will add some 
particulars of the practice of others in the disease. In the first place, 
emetics have been freely employed, and, as may be inferred from 
the accounts on the subject, with benefit. The stomach is evacu- 
ated, by an emetic, of irritating ingesta, which, despite the retching 
and vomiting that are often part of the disease, would otherwise 
remain for some time the source of continued distress; the liver is 
made to discharge more freely its bile, which finds exit not only 
upwards by the stomach, but passes downwards, and may be sup- 



[BILIOUS COLIC] 



131 



posed to contribute to a relief of the lower bowels, by either purging 
of itself, or rendering the enemata easier in their operation. But in 
addition to these commonly cited advantages alleged to follow the 
administration of an emetic, there is another and more important 
one yet which would incline me to this remedy : it is the general 
relaxation of the capillary system and diminution of vascular ex- 
citement. In order to procure this result, a selection should be 
made of that article the action of which is not limited to the sto- 
mach, but which is diffused through both the blood-vessel and 
nervous systems. I refer, of course, to the tartar emetic. Admi- 
nistered in solution, in moderate doses, at short intervals, at the out- 
set of the disease, and preceding all j other remedies, where the 
phlogosis and excitement are not thought to be sufficiently great to 
require the lancet, this medicine not only procures the desired 
evacuations, and acts as a revulsive by this means, but also, if its 
use be continued in small doses at longer intervals, it displays its 
customary counterstimulant or sedative power. In colica picto- 
num, which bears so close a resemblance to the disease in question, 
I have given the tartar emetic in this way with unequivocally good 
effect. If the spasm of the abdominal muscles and limbs should 
continue after the vomiting induced by the emetic, although in 
general we shall find it abated by this remedy, we may then add to 
the antimonial preparation small doses of opium, and continue the 
combination until the spasm is removed, and the skin becomes soft 
and moist and the pulse has lost its hardness and frequency. The 
bowels during this time should be acted on by enemata, the opera- 
tion of which will be easier after the relaxation caused by the anti- 
mony. But if free fecal evacuations cannot be procured in this way, 
and if after the operation of the emetic the stomach is still irritable, 
we then direct calomel in pill, or mixed with a little gum arabic in 
powder, and wait or quicken its action in the manner already de- 
scribed — by laxatives and enemata. 

I have said nothing respecting the effervescent draughts and the 
prescriptions in common use for sick stomach, because they are for 
the most part either inefficient or injurious. This organ is best 
tranquilized by rest from all kinds of stimuli — and by the use of the 
simpler bland or demulcent drinks in very small quantities at a 
time ; by revulsion, by means of leeches to the epigastrium, after- 
wards of stimulating liniments or sinapism to the same part and also 
to the extremities, and of enemata to evacuate the large intestines ; 
and by opium, taken sometimes by the mouth ? sometimes by the 
rectum. 

Costiveness, on occasions, continue in bilious colic in despite of 
the means hitherto recommended for its removal. Much can, I 
know, be done to prevent this morbid state by the judicious selec- 
tion and persistent use of enemata, one of the chief conditions 
for their efficacious operation being the large quantity of the 
fluid and the frequency of repetition. By some, tartar emetic in 
solution has been recommended — others lay stress on the relief 
procured by the administration of calomel in doses of one or two 



132 STOKES'S THEORY AND PRACTICE. 



grains repeated every two hours, and after the lapse of a day, 
sometimes two days, to follow up this course with the use of laxa- 
tives, if the stomach will allow N of their ingestion. I have seen this 
last treatment successful, although at the cost, sometimes, of saliva- 
tion. 

Relapses will readily occur unless proper care be exercised by 
the convalescent to protect his skin, and particularly his feet, 
against dampness and cold, to avoid all indigestible or doubtful 
food, particularly of an evening, and to keep his bowels regular. 
If the disease should have made its attack in the latter part of the 
summer, or the individual be exposed subsequently in his vocation 
to a damp atmosphere or raw w r eather, he will find his advantage 
in the use of sulphate of quinine combined with aloes, in pills, in 
such a manner that three to five grains of the former and three of 
the latter may be taken every morning before breakfast. 

Until of late years Inflammation of the Cecum, as a separate 
disease, has engaged but little attention. Dr. O'Bierne of Dublin, 
and Dr. Albers of Bonn, are our chief guides on the subject — the 
former in an article on the Inflammation and Perforative Ulcera- 
tion of the C cecum and of the Appendix Vermiformis C&ci in 
the Medico-Chirurgical Transactions, — the latter on Inflammations 
of the C&cum* To these for reference I may mention Dupuytren 
(Lecons Orales), and Ferral on Phlegmonous Tumours in the 
right iliac region — Edinb. Med. and Surg. Jour., vol. 38. 

Acute inflammation of the ccecum begins in the mucous mem- 
brane during the progress of dysentery and enteritis; but sometimes 
it arises idiopathically and unconnected with any other complaint. 
In the latter set of cases, the inflammation is usually rapid and in- 
tense. Its symptoms are, a burning, pungent pain in the right iliac 
fossa, aggravated by pressure and by intestinal evacuations, and 
frequently extending more or less along the line of the transverse 
colon. A sensation of burning heat at the anus every time that the 
bowels act is a common attendant symptom. 

Usually there is a distressing diarrhoea present, which, in general, 
diminishes the pain in the iliac fossa. The stools are thin, often 
loaded with mucus, and not unfrequently bloody. As the disease 
abates, the mucosities become whiter and of a thicker consistence, 
not unlike those which are often expectorated in bronchitis. The 
mucous secretion has frequently been mistaken for and described as 
purulent ; and hence a common error, that in this affection the 
stools are often mixed with matter. 

With respect to the pain which accompanies inflammation of the 
caecum, it deserves notice that this usually extends down the sur- 
face of the right limb, more especially when the patient walks, or 
turns his body round in bed. Hence it is apt to be considered as 

* An analysis of this last is contained in the Medico-Chirurgical Review for 
April, 1840, and from it I draw on this occasion. 



[INFLAMMATION OF THE CAECUM.] 133 



of rheumatic origin ; and as the muscles covering the inflamed 
bowel generally sympathize with it, there may be a degree of rheu- 
matic suffering blended with that arising from the enteritic disease. 
In some cases, retraction of the right testicle has been noticed ; 
and in others, symptoms of irritated kidney appear. 

The duration of inflammation of the caecum has never, to Pro- 
fessor Albers's knowledge, extended longer than seven days. 

Inflammation of the cellular tissue round the ccBCum commences 
suddenly after exposure to cold, irregularity of diet, or taking a 
draught of cold liquid when the body is heated and perspiring. The 
pain which attends it is felt at first sometimes near the umbilicus, 
and at other times in the iliac region. When it begins around 
the navel, the patient usually complains of slight cutting pains, which 
do not differ much from ordinary colic : when in the iliac region, it 
is much more intense. Wherever situated it gradually diffuses 
itself, so that the entire surface of the abdomen soon becomes ex- 
ceedingly tender, as is the case in genuine peritonitis. Sometimes 
the pain extends round to the loins and back, and then the cases 
may be mistaken for nephritis or psoitis. But at length it is concen- 
trated chiefly in the iliac fossa. When this takes place the disease 
is fully developed, and suppuration is probably near at hand. The 
pain is aggravated by any movement of the body, or by the accu- 
mulation of flatulence in the bowels, &c. When the pain has lasted 
for some time there is always considerable tension, swelling and 
hardness in the right iliac region, stretching from thence in all 
directions, but chiefly downwards in the direction of Poupart's liga- 
ment. These phenomena are more circumscribed than in peritonic 
inflammation; although it must be admitted that the two cases are 
not easily distinguishable. The following is an example of the diffi- 
culty of diagnosis : — 

A child, eight years of age, was suddenly seized, after a chill, with considera- 
ble fever attended with severe abdominal pain, which was seated at first in the 
epigastrium, and gradually extended itself to the right iliac region, and finally 
over the whole abdomen. There had been diarrhoea; but this was replaced by 
constipation and troublesome vomiting. The case was considered as one of 
genuine peritonitis, and treated with bloodlettings, local and general, fomentations, 
mercury internally and externally, &c. The patient died on the ninth day from 
the attack. Dissection showed the whole extent of the peritoneum, intestinal as 
well as abdominal, to be perfectly sound, with the exception of one spot about the 
size of a dollar over the ceecum, where it was evidently inflamed, and exhibited a 
few floculi of coagulable lymph. On examining more minutely the parts at this 
region, a fluctuation was perceptible ; and, on making an incision there, a large 
cupful of purulent matter flowed out. The cellular tissue, surrounding the 
ceecum behind, was found to be greatly destroyed by suppuration, and the pus had 
made its way between the abdominal muscles forwards to the iliac region. 
These muscles were quite dissected, as it were, from the subjacent peritoneum ; 
the caecum also was much softened in texture, so that it was easily torn across ; 
and its mucous surface was of an almost livid colour : no perforation, however, 
had taken place. All the other abdominal viscera were sound. 

It will be observed that in the case now related there was at 
first diarrhoea, which was followed by obstinate constipation. 
Such is the usual occurrence whenever the cellular substance 



134 



STOKES'S THEORY AND PRACTICE. 



around the caecum becomes inflamed. The constipation here is 
partly owing, we may suppose, to the loss of contractility in the 
muscular coat of the intestine by inflammation, and partly to the 
mechanical pressure of the swelling in the caecum, and on the 
colon also and small bowels. In addition to the symptoms already 
enumerated, there is usually pain and a sense of numbness down 
and about the hip-joint. These symptoms may be owing to the 
psoas and iliacus interims muscles being peculiarly affected. The 
excretion of urine is also in many cases more or less disturbed. 
It is probable that the right kidney sympathizes from the very begin- 
ning of the disease, and that the swelling in the latter stage may 
press upon the ureter. 

It may be readily supposed that there is generally more or less 
feverish irritation present. The progress of the disease is often 
very obscure and slow ; the symptoms being at first inconsidera- 
ble, but becoming on a sudden violent and most alarming. The 
duration of the disease may be said to vary from two or three 
weeks to several months, or even to upwards of a year. — Termina- 
tion. It is, we are told, not rare for the inflammation of the cellular 
substance round the caecum to terminate favourably by resolution, 
but certainly in the majority of cases suppuration is induced. The 
pus usually finds its way into the cavity of the gut, either directly, 
or by bursting into the appendix vermiformis. When this takes 
place there is a sudden change in all the symptoms ; the severe 
pain and the obstinately confined state of the bowels being gener- 
ally followed by a complete remission of suffering and by a greater 
or less degree of diarrhoea ; so that the patient, and his medical 
attendant, also, if he be not on his guard, are apt to suppose that a 
favourable crisis has taken place. v Too often, however, this is but 
a delusive calm ; the strength of the patient becomes weaker and 
weaker, the stools are found to be mixed with purulent matter, and 
the system at length gives way. The history of the following case 
affords a good illustration of the usual progress of the disease: — 

" Case. — -A man, twenty-nine of age, who had been previously in perfect health, 
was seized, during the Summer of 1833, when the influenza was prevailing, with 
smart abdominal pains, which returned at periodic intervals, but were not attended 
with fever or any gastric disturbance ; diarrhoea however was present. By the 
use of cupping the pains abated, but they became more permanent and more fixed 
in the right iliac region ; and at the same time a constipated state of the bowels 
ensued. For five days the patient was able to attend to his affairs ; and then he 
was seized with feverish chills followed by flushes of heat. The pain became 
much more severe, and occasional vomitings supervened; at the same time the groin 
was somewhat swollen and very tender on pressure, and the urine was thick and 
very red. Purulent matter was observed to be mixed with the alvine dejections ; 
all the symptoms became suddenly very alarming, the extremities being cold 
and the pulse scarcely perceptible; and the patient died in a state of coma. 

*' On dissection, a large collection of pus was found behind the caecum, stretch- 
ing up to the right kidney, and down to the pelvis ; the appendix vermiformis 
was hard and thickened. In the caecum, at about an inch from the appendix, 
there was a perforation with irregular edges, through which the matter had escaped 
into its cavity ; the right kidney was softened and very red ; and the iliacus in- 
tern us muscle was partially destroyed by ulcerative absorption. 



[INFLAMMATION OF THE C^CUM.] 



135 



" In a few rare cases, the pus makes its way not only into the gut, but also 
outwardly through the abdominal parietes ; thus an anus contra naturam is es- 
tablished. Occasionally the outward opening alone takes place. When this 
is the case, the symptoms are generally very severe for ten or twelve days, and 
then suddenly they subside, when the abscess bursts. Under all circumstances 
the disease must always be considered as a very dangerous one; the colliqua- 
tive exhaustion that is induced by the protracted suppuration, pjoving in most 
cases fatal. 

" With respect to the age, at which peri-csecal suppurations are most frequent, 
perhaps it is that of youth." 

The treatment of cascitis may be pretty well inferred from the de- 
scription of the disease. It will be nearly the same as that of ileitis, 
and consist of 1, leeches or cups over the iliac fossa, and behind, be- 
tween the ridge of theos innominatum and the lower rib, and anterior 
to the psoas muscles — 2, a blister, which is to be kept freely dis- 
charging, and if the symptoms persist, the surface to be dressed with 
mercurial ointment — 3, antimonials to act on the bloodvessel system, 
by reducing action; and afterwards a mild purgative, in order to 
insure a discharge from the cascum of any retained fecal or im- 
perfectly digested or other irritating matters. Active purging 
should not be produced by any medicine given by the mouth; but 
enemata may be frequently administered, partly with a view of 
revulsion, and partly of gently soliciting the passage downwards of 
the matters in the ileum, caecum, and upper part of the colon, 
the delay of which would prove irritating. Small doses of calomel 
at intervals will contribute to this end and be otherwise useful. Lo- 
cal as inflammation of the caecum is, we ought, nevertheless, in cases 
in which the pain is fixed and violent, and extends over the abdomen, 
in a young and well constituted subject, not to rely entirely on topical 
detractions of blood, but must have recourse to venesection, and 
allow the blood to flow from the arm until approaching syncope. 
Leeches to the anus will sometimes be of service, the more so if 
there have been pre-existing irritation of this part by haemorrhoids. 

Stercoral inflammation of the caecum is the occasional conse- 
quence of the protracted detention of the fecal matter in the cells 
of the caecum, until a process, at first of irritation, and afterwards 
of inflammation, is excited, and then all the^ symptoms of enteritis 
or of strangulated hernia are evinced. As obstinate constipation 
is perhaps the only symptom that is present for a great length of 
time, the physician may have no grounds to suspect any local 
mischief until swelling or pain is felt in the right groin. At this 
time the abdomen, says Professor Albers, is usually tense, hard, and 
prominent, especially at the right flank. If we attentively examine 
this part, we shall generally find that it is the seat of a large swell- 
ing, which can be displaced more easily from one side to another 
than from above downwards. At first, light frictions over this 
part will probably cause the swelling to disperse ; not so, when the 
malady is farther advanced. Pressure on the part usually causes 
a certain degree of uneasiness, but rarely any acute pain. In the 
left iliac region the descending colon may often be found filled with 
indurated faeces. A sense of pain and numbness is not unfre- 



136 



STOKES'S THEORY AND PRACTICE. 



quently felt along the line of the iliacus internus muscle, from the 
groin downwards along the inner side of the thigh ; this feeling 
usually becomes more and more distressing as the complaint ad- 
vances. A dull sound is elicited by percussion on the right iliac 
region. 

The various symptoms which attend this disorder may exist for 
several days before they come to any crisis. Professor Albers has 
observed in some cases that the most conspicuous symptom for a 
great length of time is a most troublesome itching of the surface. 
If a diarrhoea should take place either spontaneously or from the 
use of purgative medicines, the symptoms are in common relieved 
rapidty and effectually. It is truly astonishing to see what quantities 
of fecal matter have been discharged before entire relief is obtained. 

Our prognosis in this complaint is for the most part favourable. 
There are cases, however, in which the fasces are lodged perma- 
nently in the caecum, and consequently upon this state will be 
an inflammatory and perhaps suppurative action in its walls or in 
the adjacent cellular tissue. But even should the abscess burst 
outwardly, feculent matter is not always mixed with the purulent 
discharge, as the gut may never have been perforated, or the 
aperture may have been so small that it has subsequently closed 
up. Such cases not unfrequently terminate well ; the suppurative 
gradually diminishing, and the abscess at length healing up. In a 
few rare instances the inflammation has terminated in gangrene. 
Finally, though rarely, the life of the patient has been much pro- 
longed by the yielding of the bowel, and the formation of an artifi- 
cial anus in the right groin. 

The following case will illustrate some of the foregoing re- 
marks: — 

44 Case. — A man, seventy-two years of age, died last year in the Salpetriere at 
Paris, after protracted suffering from intestinal disturbances. The interior part 
of the sigmoid flexure was much contracted ; and the consequence of this lesion 
had been that an immense quantity of faeces, in large hard lumps, was accumu- 
lated in the transverse portion of the colon, which might actually be felt through 
the thin parietes of the abdomen ; the liquid parts seemed to have been, as it 
were, filtered through them, and hence during life the patient had supposed that 
he had a diarrhosa. He died suddenly and without experiencing much pain. On 
dissection, a large ulceration was found in the caecum, and a cancerous contrac- 
tion of the sigmoid flexure. 

44 In another case — which terminated favourably — where the rectum was ob- 
structed by an encephaloid tumor, the faeces had accumulated in large hard balls 
in the sigmoid flexure and descending portion of the colon. The caecum and 
rest of the colon were distended with gas. This state had continued for up- 
wards of a twelvemonth, when suddenly the abdominal parietes became the seat 
of sharp pain, which were most severe in the right groin. By the use of purga- 
tive medicines, an immense quantity of the large fecal balls was discharged, 
and the patient was speedily relieved." 

The period of duration, or the stage of stercoral inflammation of 
the caecum, will modify its treatment. When there is yet but accu- 
mulation and retention of faeces, indicated by protracted costive- 
ness and some fulness in the right iliac region, we can have recourse 
to all those means which are in common use for the relief of con- 



r [INFLAMMATION OF THE CAECUM.] 



137 



stipation. Calomel and jalap in full doses, a calomel pill of ten grains, 
followed by the compound powder of jalap, the compound extract of 
colocynth, or an infusion of senna with salts, or castor oil and spirits 
of turpentine, may, severally, be prescribed with advantage. Tartar 
emetic, in nauseating or relaxing doses, to be succeeded by active 
enemata, will sometimes procure free fecal discharges. Croton 
oil, if the stomach revolt at medicine in bulk, or if the other 
prescriptions prove unavailing, is a resource in reserve. 

But if to the symptoms of stercoral accumulation be added dif- 
fused tenderness of the abdomen, vomiting, and protrusion of the 
intestine in the groin, we should have recourse to the same reme- 
dies which are directed in strangulated hernia. Of these, venesec- 
tion or leeching, according to the constitutional vigour or evidences 
of general febrile excitement, tartar emetic, as a sedative and re- 
laxant, and enemata, will constitute the first part of the treatment. 
Relief being obtained, we may then give some tolerably active pur- 
gatives, selecting those which are least irritating to the mucous 
coat. Calomel, therefore, and castor oil, or castor oil and turpen- 
tine, will have the preference over the resinous and drastic medi- 
cines of this class. Where the muscular coat is partially paralysed 
by inflammation, or the diameter of the intestine diminished by 
external tumour, or other causes, it will be desirable to produce a 
relaxation of the whole intestine, and at the same time diminish the 
inflammation. Hence we have recourse to free leeching in the neigh- 
bourhood of the tumefied part, tartar emetic by the mouth and per 
anum, and finally, if need be, enemata of tobacco, as used for hernia, 
and as successfully employed by Dr. O'Beirne in dysentery. We must 
not forget the means of at least partial relief afforded by the elastic 
tube introduced some way up the gut, as already recommended in 
colic and tympanites, p. 127. In all cases in which an enema is to 
be administered, the pipe projecting from the barrel ought to be longer 
than it is; or the defect in this particular may be supplied by the affix- 
ing to it an elastic tube, which, especially in cases of obstinate consti- 
pation and colic, or where stricture of the rectum exists or is sus- 
pected, should be carried high up in the intestine ; as far, at least, as 
the sigmoid flexure of the colon. Knowing the immense quantitity of 
accumulated faeces which have sometimes been retained in and dis- 
tended the caecum and colon, we ought not to desist from a continua- 
tion of our measures for their entire evacuation, even after the fecal 
discharges have been copious. We may remit, for a day or two, 
the administration of purgatives after ease has been procured by 
large discharges of scybala and faeces ; and then resume the use 
of this class of medicines, varying the kind so as at one time to give 
saline, at another resinous, then again oleaginous. The increased 
activity and milder operation of certain purgatives are obtained by 
the addition of a bitter, as quinine, gentian, &c. 

Frequent and regular friction, and gentle kneading of the abdomi- 
nal parietes; the tepid bath at first, and afterwards the cool shower 
bath or douches along the spine, and moderate exercise in the open 

13 



138 



STOKES'S THEORY AND PRACTICE. 



air, will be among the measures of restoration recommended to the 
convalescent from this disease. Great attention will be demanded 
in reference to the kind of food used, so that it be light and easy of 
digestion, and tending to keep the bowels in a soluble state. 

A few remarks on Tuphlo-Enteritis, or Inflammation and Perfo- 
rative Ulceration of the Ccecum, and of the Appendix Vermiformes 
Cceci, will close my notes on the diseases of the intestines. Dr. 
Burne, remarks : The peculiarity in the organization of the caecum, 
•which bears upon the present subject, is the absence of a peritoneal 
tunic at its posterior part, where it is fixed and attached by adi- 
pose cellular tissue to the iliac fascia, so that in the event of a per- 
forative ulceration in this direction an abscess would form behind, 
and without the peritoneum upon the iliac fascia r and direct its 
course to the lumbar region at the outer edge of the quadratus 
lumborum muscles. Dr. Burne, in premising that the caecum by its 
conformation is peculiarly exposed to the lodgment of undigested 
substances, thinks that the greater number of cases of inflammation 
of this intestine are to be ascribed to the prolonged irritation of 
bodies so lodged, and that such inflammations are, therefore, pro- 
perly symptomatic ; a conclusion borne out, moreover, by the manner 
of the attack, which is characterized by a development of the local 
preceding that of the general symptoms, and by the absence of the 
chills and rigors which usher on idiopathic inflammation. That the 
inflammation of the caecum may be idiopathic, and arise from the 
ordinary exciting causes, cold and vicissitudes of the w ? eather, 
there can be no doubt; but these instances are rare, in comparison 
with those which may be fairly attributed to the irritation of crude 
substances which have reached the caecum and lodged in its pouch. 

The termination of the symptomatic inflammation of the caecum 
is usually by resolution; the symptoms yielding at the end of five 
or six days, and subsiding altogether soon afterwards ; except in 
patients of an inflammatory or gouty diathesis, in whom inflamma- 
tion once excited will continue in a sub-acute or chronic form, 
and require several weeks for its removal, notwithstanding the 
original exciting cause shall have passed away. 

The termination by perforative ulceration and abscess of the 
caecum is rare: but this organic lesion of the appendix is more apt 
to occur, and is next in frequency to the inflammation of the caecum. 

The varieties of the disease are — 1. Inflammation, acute or sub- 
acute, of the caecum, terminating quickly or slowly in resolution, 
or lingering on, and leading to permanent organic impairment. 
2. Perforative ulceration of thecaecum from within, and abscess behind 
the peritoneum, pointing externally in the corresponding lumbar, 
or inguinal region, or in both. 3. Inflammation of the appendix^ 
spreading over the peritoneum. 4. Perforative ulceration of the ap- 
pendix, with consequent universal peritonitis, ending rapidly in 
death, or with circumscribed peritonitis, and abscess within the peri- 
toneum, sometimes ending in death in the course of ten days, or, 
life being preserved, it bursts eventually into the caecum, and dis- 



I 



[TUPHLO-ENTERITIS.] 



139 



j charges itself by the rectum, or directs its course to the surface of 
| the body, and pointing in the right lumbar or inguinal region. 

As regards the tumour which occurs in the right iliac fossa, Dr. 
I Burne assigns the following as its causes: — 1. Collection of fecal 
| matter in the csecum. 2. The presence of any crude undigested sub- 
j stance, of worms, concretions, or other foreign bodies. 3. Inflamma- 
1 tion of the caecum, resulting from the irritation of the above. 
4. Chronic disease of the caecum. 5. Abscess from perforative 
ulceration either of the caecum or of the appendix. 

The perforative ulceration of the appendix may be suspected by 
the more or less sudden development of the local signs, which are 
always severe, by their being fixed in the right iliac fossa, and not pre- 
ceded by bowel complaints or ill health; by the supervention of 
vomiting and constipation, the constipation yielding readily to medi- 
cine ; yet, having yielded, no amendment following; by the great 
tension of the ileo-inguinal region, there being always a circum- 
scribed peritonitis and abscess within the peritoneum; by the sym- 
pathetic tenderness of the whole abdomen ; and subsequently, by the 
occurrence of a diarrhoea, and a discharge of pus by the rectum, 
followed by subsidence of the tumour and amelioration of all the 
symptoms, or by the pointing of the abscess in the form of an em- 
physematous tumour in the lumbar-inguinal, or ileo-inguinal regions. 

The peritonitis excited at the moment of the perforation of the 
appendix, will not unfrequently spread rapidly and universally over the 
peritoneum, and destroy life in from twelve to twenty-four hours. 

The diagnosis in the two varieties of the disease will be the less 
doubtful by our remembering that the perforation of the caecum is 
generally preceded for weeks or months by bowel complaints, indicat- 
ing ulceration of the mucous membrane ; while the perforation of 
the appendix is not preceded by such bowel complaints. 

The statistical information afforded by the cases collected by 
Dr. Burne, is presented as follows: — Termination : 13'recovered, 8 
died. Character: 19 acute; 2 chronic. Varieties: 11 were in- 
flammation of the caecum — all recovered : 2 were chronic disease 
of the caecum — both died : 1 was ulcerative perforation of the 
caecum from within, with abscess externally — recovered: 1 was 
inflammation of the appendix, with circumscribed peritonitis — died. 
6 were ulcerative inflammation of the appendix — 5 died, 1 reco- 
vered. Of the five fatal cases of perforative ulceration of the 
appendix, one died of diffuse peritonitis in about sixty hours ; one 
of peritonitis and circumscribed abscess in the peritoneum in nine 
days ; one of circumscribed peritonitis and abscess in the peri- 
toneum in twelve days ; one of circumscribed abscess in the peri- 
toneum in four weeks ; and one of abscess in the peritoneum, point- 
ing in the right ileo-lumbar region, in eleven days. "The one 
which recovered was a circumscribed abscess in the peritoneum 
bursting into the caecum. 

The ages were, two Under ten years of age, seven between ten 
and twenty ; three between twenty and thirty ; six between thirty 



140 STOKES'S THEORY AND PRACTICE. 

and fifty ; three between fifty and seventy. Sex : sixteen were 
males ; fi ve were females. Occupation : six were gentlemen ; one 
was a coachman; one a farmer; five were boys having no par- j 
ticular occupation ; three were destitute; five were females having 
no particular occupation. Season : In the autumn and beginning 
of winter more frequently. — B.] 



LECTURE XII. 

Pathology of jaundice — Its co-existence with a flow of bile — Case of aneurism of the 
hepatic artery — The disease, independent of mechanical construction — Colouring of 
the various parts — Effects on the milk, and humours of the eye — Jaundice with pre- 
servation of health — Icterus infantum. 

To-day we have to enter upon the consideration of a subject, the 
nature and extent of which claims for it a more than ordinary share 
of importance — I allude to that form of disease which is termed 
jaundice. I have selected this disease for our present lecture, be- 
cause I think we may look upon it as presenting a series of pheno- 
mena, which form a distinct link of connection between affections 
of the liver and the digestive tube. In the first place, jaundice, and 
I wish to impress this upon your attention, is to be regarded as a 
symptom rather than a disease sui generis, and that it is a symptom 
which occurs in many diseases of a most essentially opposite patho- 
logical character. There is nothing, for instance, more different 
than disease accompanied by acute inflammatory action, and disease 
without any inflammation at all; yet we may have perfect jaundice 
as a consequence of the one as well as the other. No diversity can 
be more complete than that which exists between the jaundice 
arising from inflammation and organic lesion of the liver, and that 
which results from simple mechanical obstruction of the biliary \ 
ducts. It is, therefore, to be looked upon not as a disease but as a 
symptom, and w 7 e may define it by saying, that it is a state in j 
which the solids and fluids of the body are tinged more or less 
deeply with bile. Generally speaking, this presence of bile in 
fluids and solids where it should not be normally, is accompanied 
by the absence of that secretion in the place where it is naturally 
found, the digestive tube. Yet it is an interesting physiological 
fact, and one of practical importance, also, that we may have plenty 
of bile in the stools during an attack of jaundice, or that we may 
have jaundice co-existing with even a copious flow of bile. This 
is a strong proof in favour of the opinion, that some cases of jaun- 
dice have no connection or dependence on the absorption of bile 
into the system, as, in the instances to which I have alluded, there 
is no mechanical retention of bile ; the biliary ducts and gall bladder 
are open, the bile passes freely into the intestines, and yet the whole 
body is jaundiced. 

I have told you that jaundice is a symptom which is produced by 



PATHOLOGY OF JAUNDICE. 



141 



a variety of causes — these I shall briefly enumerate. Without 
entering into the ultimate mode of action of these causes, and their 
separate effects on the economy, it will be sufficient for my purpose 
to mention them individually. The first of these causes I take to 
be mechanical obstruction to the exit of the biliary secretion. 
Under such circumstances one of these two things is supposed to 
take place, either that the bile, which is poured into the biliary 
duct and gall-bladder, and cannot get into the duodenum, is re- 
absorbed, or, according to another opinion, that the innervation of 
the liver is injured ; in other words, that the liver is paralysed and 
unable to perform its ordinary functions, and that, consequently, it 
does not separate the materials of bile from the blood. The latter 
opinion has been advanced by men of high authority in the medical 
world, but when we find, on dissection, (as is not unfrequently the 
case in jaundice,) the biliary ducts and gall-bladder distended with 
bile, we cannot infer a paralysis of the liver as the cause of the 
disease, we must attribute it to the reabsorption of bile. I have 
taken mechanical obstruction to the flow of bile as one of the causes 
of jaundice. Now, you will find this to depend, in the first place, 
upon the presence of gall stones in the biliary or common ducts. 
A biliary calculus is formed in one of these ducts, it excites violent 
irritation, spasmodic pain, and often (but not always) jaundice. At 
my next lecture I will show some specimens of this obstruction. 
In the second place, the biliary ducts may, from various causes, 
become obliterated ; they may be closed by adhesion, as the conse- 
quence of inflammation, or they may be impervious as the result of 
congenital malformation. In some cases children have been born 
without biliary ducts, in others the ducts have terminated in a cul- 
de-sac. A third case of jaundice by mechanical obstruction is, 
where the flow of bile has been prevented by the pressure of 
tumours on the biliary ducts. Of this one of the most familiar in- 
stances is disease of the head of the pancreas, or malignant disease 
of the pylorus or duodenum. I have on a former occasion alluded 
to a case of jaundice produced by aneurism of the hepatic artery, 
• one of the rarest pathological circumstances on record, and one 
which has not been hitherto described. So rare is it, that at a late 
meeting of the Academic de Medicine, that eminent pathologist, 
Cruveilhier, stated that he had never seen a case of it. I was so 
fortunate as to meet with an instance of this uncommon form of 
disease, and will take an early opportunity of exhibiting the prepa- 
ration of it to the class. You will see by it how an aneurism of the 
hepatic artery may cause a complete obstruction to the flow of bile, 
and I shall be able to show you, that not only the trunks, but also 
the minute ramifications of the biliary ducts, are enormously dilated 
and filled with retained bile, and that these dilatations are continued 
up to the peritoneal surface of the liver, forming as it were so many 
aneurisms by dilatation of the biliary ducts themselves. The last 
cause of jaundice from mechanical obstruction, is that which de- 
pends upon the accumulation of scybalous matter in the bowels, a 

13* 



142 



STOKES'S THEORY AND PRACTICE. 



thing frequently met with in old persons. Dr. Marsh alludes to 
this form of the disease in his admirable paper on jaundice in the 
Dublin Hospital Reports, and brings forward cases in which the 
jaundice disappeared rapidly under treatment calculated to remove 
accumulations of hard fecal matter from the intestines. So much 
for the varieties of jaundice which depend upon mechanical ob- 
struction. Before I quit this part of the subject it will be necessary 
to allude to another form of the disease, which bears some analogy 
to those already mentioned, namely, the spasmodic jaundice. With 
respect to this variety there exists a great deal of doubt ; some per- 
sons maintain that the ducts are muscular, and consequently liable 
to spasm like all other parts of the muscular system ; others deny 
the existence of muscular fibres in the ducts; while a third party 
are of opinion that the spasm resides in the duodenum, and that 
the contraction of its muscular fibres is the sole obstacle to the free 
passage of bile. It is of very little consequence which of these 
opinions w 7 e adopt ; the fact is, that this is a' form of the disease 
which we occasionally meet with in persons of an hysterical or 
hypochondriac habit, but what is its exact seat we cannot ascertain. 
The probability is, that it is spasm of the duodenum itself. 

The next class of causes giving rise to jaundice, are those which 
are connected with acute or chronic disease of the liver, as, for 
instance, the different varieties of hepatitis and the existence of mor- 
bid growths in the substance of the liver. Here, however, it must 
be recollected that the occurrence of hepatic disease in the acute or 
chronic form does not necessarily imply the existence of jaundice ; 
in other words, there are some cases of disease of the liver in which 
bile is freely discharged into the digestive tube, others in which it 
is not, so that the non-secretion of bile and the consequent produc- 
tion of jaundice are to be looked upon as accidental complications. 
I have seen a case in which there was enormous destruction of the 
liver from suppuration, where one of the lobes w 7 as almost entirely 
converted into a bag of purulent matter, and the other extensively 
diseased, yet the patient had not the slightest tinge of jaundice. 
We are ignorant, therefore, of the cause which determines the* 
production of jaundice in one case of hepatic disease, and not in 
another ; the question remains to be decided by future investiga- 
tions. All we know is this, that it may occur or be absent in every 
form of acute or chronic disease of the liver. 

The third great source of this affection is disease of the mucous 
surface of the stomach and duodenum, the most important, because 
it is the most frequent, cause of jaundice. We are indebted to the 
researches of modern pathology for a correct notion of this form of 
the disease, and for the invaluable light thrown upon its treatment, 
which, up to the time of Broussais, had been extremely confused 
and empirical. Inflammation of the upper part of the digestive 
tube is an extremely frequent cause of jaundice, and this result is, 
generally speaking, independent of any mechanical obstruction of 
the gall-bladder or biliary ducts. This phenomenon may be ex- 



PATHOLOGY OF JAUNDICE. 



143 



plained by calling to mind the various examples of sympathetic 
irritation, and by recollecting that disease in one situation frequently 
produces disease in another, or, in other words, that we have an 
irritation of the stomach and duodenum, in which the liver sympa- 
thetically partakes, and, as a consequence of this, the biliary secre- 
tion is arrested. In a former lecture, I alluded to the strong sym- 
pathy which is known to exist between mucous membranes and 
the glands whose ducts open upon their surfaces. It is supposed 
by some that the irritation existing in the duodenum may be ex- 
tended to the liver, producing paralysis of the functions of that 
organ and jaundice. It would appear, also, that the yellow fever 
of warm climates is only a variety of jaundice depending upon 
irritation of the gastro-intestinal surface. On this point the best 
pathologists seem to have made up their minds. 

The last cause of jaundice seems to consist of the sympathetic 
action of the brain upon the liver, and this is an extremely curious 
circumstance. There are numerous cases on record of persons 
who have received an injury of the brain becoming jaundiced, and 
the same affection has been repeatedly known to supervene on pow T - 
erful mental emotion. Thus we find that Murat, on learning that 
his queen had assumed the sovereign power of Naples in his 
absence, fell into a violent passion, and became almost immediately 
jaundiced. The close connection which "exists between the brain 
and the biliary system has been long known; it is unnecessary, 
therefore, that I should enter upon its consideration, for the purpose 
of accounting for an occurrence the nature of which must be ob- 
vious to all. You will, however, find that jaundice is, in the 
majority of cases, connected with disease of the gastro-intestinal 
surface, and that this is one of the most common causes of the 
sporadic jaundice of this country. I shall return to this subject on 
a future occasion, when we enter upon the consideration of hys- 
teria. 

Before I enter upon a description of the separate forms of jaun- 
dice, it will not be amiss to premise a few general remarks. I told 
you at the commencement of my lecture, that we define jaundice 
by saying, it was that state in which the solids and fluids of the 
body were tinged more or less deeply with bile. Now, is this 
definition to be received without any exception ? and does it em- 
brace all the solids and all the fluids of the body ? I have stated, 
that in some cases you will not be able to detect the slightest trace 
of bile in the stools. This is, however, but an apparent exception; 
it is, perhaps, because the bile is too small in quantity to be able to 
overcome the diluting power of the ingesta, or that the portion of it 
which finds its way into the digestive tube is too small to be appre- 
ciable by our senses under these circumstances. The rule of uni- 
versal colouring in this disease will not, I believe, hold good, at 
least there are certain fluids and solids which are tinged only in a 
very slight degree ; but the majority of the textures and fluids have 
been observed to be more or less distinctly coloured. For instance, 



144 



STOKES'S THEORY AND PRACTICE. 



we find the jaundiced tint appearing in bone, cartilage, muscle, in 
the cellular membrane, in the central portions of the teeth, but not 
in their enamel. It is doubted whether the hair is coloured or not, 
but it is the opinion of many that it is, and a professional friend of 
mine has assured me that he has had unquestionable proofs of the 
colouring of the hair. The membranes of the brain are distinctly 
tinged. I have seen the arachnoid and pia mater decidedly coloured 
in a case of dreadful gastro-duodenitis, to which I shall call your 
attention on a future occasion. The substance of the brain, how- 
ever, has not been found to partake in this universal discoloration. 
Frank, who is a good authority on this point, states that the sub- 
stance of the brain is never coloured, though the membranes may, 
and most commonly are. In my experience of jaundice, I have 
found the membrane distinctly coloured, but never could see any 
tinge of yellowness in the substance of the brain. I have how- 
ever observed, that when a horizontal section of the brain had been 
made in such cases, the orifices of the divided vessels, which are 
denoted by bloody points in the healthy state, seems to pour out a 
quantity of yellowish blood, but the substance of the brain appeared 
white and normal. 

With respect to the state of the fluids, you will find the blood 
distinctly coloured ; the saliva also is yellow ; the urine is loaded 
with bile, it stains the linen, and chemical analysis shows that a 
large proportion of the biliary secretions in blended with it. The 
perspiration is also tinged with it ; and if you apply a blister you 
find the exuded serum bilious. If a person, labouring under phthisis 
or bronchitis, should happen to get an attack of jaundice, the pul- 
monary secretions will be often tinged with yellow. The mucous 
secretions from the vagina and uterus are also discoloured ; but it 
is an interesting and curious fact, that the milk during lactation 
seems to escape the general impregnation with bile, and is never 
tinged. This would appear to be a beautiful provision of nature to 
prevent the child from being injured. Frank, who witnessed two 
epidemics of jaundice, one at Mayence, in 1754, and another at 
Ghent, 1742, states that he has never seen the milk tinged with 
bile. Dr. Marsh, in his paper on jaundice, mentions that in the 
case of one unfortunate female a yellow fluid was squeezed from 
the breasts after death ; but this cannot be considered as a proof of 
the existence of bile in the milk during life. 

In jaundice the eye almost always presents a very distinct yellow 
tinge, and yet it is a curious and interesting fact, that the patients 
very seldom complain of yellow vision. Out of several thousand 
cases of jaundice, Frank only met with five in which this symptom 
was observed. The occasional occurrence, however, of yellow 
vision in jaundice, has excited a good deal of interest; and Drs. 
Graves and Elliotson, who have turned their attention to this sub- 
ject, have made some ingenious and valuable remarks on this sin- 
gular phenomenon. Dr. Elliotson's opinion is, that where this 
symptom is complained of, the cornea is in a state of irritation or 



PATHOLOGY OF JAUNDICE. 



145 



inflammation, and that under these circumstances its vessels, which 
in their physiological condition are too small to allow of the passage 
of coloured fluids, become dilated, so as to carry bilious blood across 
the field of vision, and thus cause all objects to wear a yellow hue. 
To support this opinion, he brings forward the case of a jaundiced 
patient, who had a considerable degree of inflammation in one eye 
but none at all in the other, and who saw objects yellow with the 
inflamed eye, but of their natural colour with that which was free 
from inflammation. This case is, indeed, as far as it goes, extremely 
interesting ; but I think it does not prove the point in question, 
namely, that the cause of jaundiced vision is irritation of the cornea, 
for it is a fact that even when the cornea is deeply tinged, yellow 
vision is not of constant occurrence, nor does it affect all persons 
alike. One person sees objects in their natural colours ; to another 
under the same circumstances every object appears to wear a 
yellow hue, and what is equally remarkable, this yellowness of 
vision is frequently intermittent ; it is present to-day and disappears 
to-morrow. These are extremely curious facts. 

The object of Dr. Graves on this subject, in the Dublin Medical 
Journal, is to explain the cause of the absence of yellow vision in 
certain cases of jaundice. He believes that the humours of the eye 
frequently escape the jaundiced tinge, and suggests that this may 
be a beautiful provision of nature for the preservation of sight. 
From his own observations he states that the aqueous, and perhaps 
the vitreous, humours escape. But, it may be objected to this, that 
when all the fluids, the blood, saliva, serum, perspiration, &c, are 
impregnated with bile, how is it possible that the fluids of the eye 
should escape? — Does it not seem very extraordinary? — It does, 
certainly; but that it is possible seems to be established by the fol- 
lowing circumstances; — you are not to conclude, because all the 
fluids which are found to exist in the blood are filled with bile, that 
the secretions, properly so called, which do not exist in the blood, 
should be also tinged with bilious discoloration. This is the an- 
swer which Dr. Graves makes to this objection — I recollect two 
cases of malignant ^ancerous disease of the liver, which were some 
| time ago in the Meath Hospital, and which presented symptoms of 
universal jaundice before death. In these cases we 'found fluids 
deeply impregnated with bile— everything, in fact, seemed bilious 
and discoloured; and yet, you will* hardly credit me when I tell 
you, that, on opening the gall-bladder, it was found to contain a 
quantity of beautiful limpid fluid, perfectly transparent, and of a 
: high refractive power. Here, then, is a fact to prove that we may 
have intense general jaundice, and yet find in a sac, existing in a 
| system so diseased, a quantity of fluid perfectly free from any bilious 
j admixture, proving, at least, that it is possible that the humours of 
i the eye may in a similar manner escape. Dr. Graves further 
| remarks, that, even where the humours of the eye happen to be- 
j come tinged, the alteration in the colour of objects may still escape 
I the observation of the patient ; because the change takes place gra- 



146 STOKES'S THEORY AND PRACTICE. 



dually and insensibly. The patient does not think everything he 
sees is yellow ; he believes still that they are white, because the 
transition from one colour to the other has been so insensible as to 
escape his notice. This reasoning may, I think, apply to cases of 
yellow vision coming on gradually, but will not explain those in 
which it has been of sudden occurrence. The other cause which 
Dr. Graves adduces as tending to prevent a patient with a yellow 
cornea from seeing objects of the same colour, is, the want of some 
standard of comparison to judge by. He has no means of compar- 
ing objects ; and, though he sees this piece of paper, for instance, 
(yellow,) he thinks it white, because every standard he looks to, 
every other piece of paper he examines, presents the same tinge. 
Dr. Johnson states, that most of the jaundiced patients whom he 
has interrogated were sensible of the alteration in vision to a greater 
or less degree, and observes that the power of appreciating varieties 
of colour is retained, though we look through a yellow medium not 
deeply dyed, though yellow, of course, is made to enter into this 
composition. You will see this observation in the Medical Chirur- 
gical Review for October, 1833. 

I shall conclude this subject with an observation which suggests 
itself to me, and this is, that the alteration of colour and vision may 
arise from other causes than the mere jaundiced condition of the 
eye ; and that it may (I believe this has not been taken notice of 
before) depend upon direct nervous influence. There are cases on 
record of patients labouring under typhus fever, who, without 
being m the slightest degree jaundiced, saw everything yellow. 
There are also numerous instances of various colours, differing 
from the natural hues of the objects, being seen by patients in con- 
sequence of affections of the nervous system ; and hence it is ex- 
tremely probable that many cases of yellow vision in jaundice may 
depend upon a functional lesion of the optic nerves. I have one 
fact to bring forward on this subject of great importance. In the 
case of jaundice from aneurism of the hepatic artery, the patient 
saw everything intensely yellow, until a few days before death, 
when all yellow vision subsided, and he saw objects of their natural 
colour, though the jaundice continued, if possible, more intense 
than ever. In this case there was no inflammation of the eye. I 
do not think that Dr. Elliotson's observations apply to all cases of 
this phenomenon. All that he has said is that where the cornea is 
in a state of inflammation, there is a greater probability that there 
will be yellow vision in the affected eye or eyes ; and this can be 
easily accounted for by the increased size of the vessels which the 
inflammatory process brings on. We may however conclude, that 
in some cases, the alteration of vision may be owing to a yellow 
state of the humours of the eye, that in some it is the result of in- 
flammation, and that in some it may be fairly attributed to a lesion 
of innervation. I think that the latter statement is borne out by the 
facts that there is a want of constancy in the occurrence of this 
phenomenon, that it is often of a more or less intermittent character 



PATHOLOGY OF JAUNDICE. 



147 



being one day present and another day absent, and that it has been 
observed in cases where not the slightest symptom of jaundice ex- 
isted. We must also bear in mind that some of the most remark- 
able nervous systems commonly occur in jaundice, such as coma, 
&c. ; and we may inquire how far the occurrence of yellow vision 
may be looked on as an indication of an excited state of the 
brain, and so lead us to measures calculated to remove impending 
danger. 

Let us now return to the more immediate consideration of jaun- 
dice. One of the first diseases of children is the icterus infantum, 
or, as it has been termed by nurses, the yellow gum. Children, 
shortly after birth, without any known cause, become suddenly 
jaundiced, and this, after continuing for some days, goes off, fre- 
quently without any treatment. This form of jaundice appears to 
depend upon some particular irritation of the intestinal canal, which 
seems to result from the circumstance of the digestive system being 
called into active exertion for the first time, and receiving a new 
stimulus from the mother's milk. It is a curious fact, that this form 
of jaundice generally disappears spontaneously. Now it is remark- 
able, in this as well as other cases, (when we recollect the nature of 
jaundice, and that there exists in the fluids of the body an irritating 
substance like bile,) that the effects of an admixture of the biliary 
secretion with those fluids should not be attended with more striking 
symptoms. In some instances we shall have intense jaundice 
without any particular effect upon the economy. There is some 
itching of skin, ardor urinse, a little depression of spirits, and 
vertigo, which last for a few days and then disappear. Dr. Gre- 
gory mentions many cases of persons affected with jaundice who 
went about their ordinary business, and performed all the functions 
as if in a state of perfect health, eating, drinking, and sleeping in 
their usual manner. I have myself seen persons who laboured 
under this affection for more than a year, and yet had all that time 
their digestion good, their bowels regular, the flow of urine natural, 
and the circulatory, nervous, and respiratory systems apparently 
conformable to the standard of health. Dr. Blundell gives the 
cases of two children who lived for four months, apparently well 
fed and healthy ; and, on opening their bodies, 'it was found that 
the biliary ducts terminated in a cul-de-sac, and that, consequently, 
not a drop of bile had been discharged into the intestines. Sir 
Everard Home gives a remarkable case of the total absence of the 
gall-bladder, and no passage of bile into the intestines, occurring in 
connection with a perfect state of health. These are curious facts, 
and should be borne in memory. I remember two cases of pro- 
tracted jaundice in the persons of two male servants who were 
admitted into the Meath Hospital with symptoms of irritation in the 
| upper part of the digestive tube. From this both recovered under 
! an appropriate treatment, but the jaundice continued in one for 
! eighteen, and in the other for sixteen months. One of them, a 
I stout, well-built, and fully developed man, came into the hospital 



148 



STOKES'S THEORY AND PRACTICE. 



some time afterwards in the apparent enjoyment of perfect health, 
except that he had still the jaundiced colour. He wished to be 
taken into the hospital to get cured of his jaundice, stating that, in 
consequence of the peculiarity of his appearance, he could not get a 
place anywhere, and was in a very distressed condition. From 
these facts it seems fair to conclude that the symptoms of other 
affections, occurring after jaundice, are owing to some other cause 
than the bilious state of the blood. 

I find that my time is nearly expired ; I cannot, therefore, enter 
into the various causes of jaundice to-day; at our next meeting I 
hope I shall be able to conclude this subject, and then pass on to the 
consideration of hepatic disease. 



LECTURE XIII. 

Jaundice from gastro-duodenitis — Researches of Broussais and Marsh on — Jaundice 
without hepatic inflammation — Nervous symptoms — Treatment — Yellow fever — its 
occurrence in this country — Predominance of gastric irritation in warm climates — 
Typhus icterodes — Jaundice from biliary calculi — Different situations in which 
biliary calculi may be found. 

We commence to-day with the consideration of that form of jaun- 
dice, which, taking all its cases into account, appears to be the most 
common. The pathological expression for this form of the disease 
is, that it is inflammation of the upper portion of the digestive tube, 
or, in other words, that it is the result of a gastro-duodenitis. In 
this case, an inflammatory affection of the stomach and duodenum 
acts sympathetically on the liver, and we have jaundice occurring 
independent of hepatic inflammation or mechanical obstruction to 
the flow of bile. This variety of the disease it is important you 
should be accurately acquainted with, as it is not only exceedingly 
common in temperate climates, but because I believe it is a great 
cause of mortality in warm countries, and that the yellow fever of 
the tropics is reducible, in a great measure, to this form of disease. 
In other words, that the cause of the yellowness, and many other 
of the symptoms, is to be referred to an intense irritation or inflam- 
mation of the digestive tube, with a predominance of that irritation 
in its upper portion. 

The jaundice which depends upon gastro-duodenal inflammation, 
was first accurately described by Broussais. Dr. Marsh has also 
made many valuable additions to our knowledge on this subject, in 
his paper on jaundice, published in the fifth volume of the Dublin 
Hospital Reports. You will find, too, that in a case of jaundice 
described by John Hunter, he suggests the possibility of its being 
preceded by inflammation of the duodenum. But I believe we are 
chiefly indebted to Broussais for our first correct notions of the 
pathology of this disease, and for its scientific and successful treat- 
ment. 



JAUNDICE FROM G ASTRO-DUODENITIS. 149 



The disease may occur in the acute form, or it may come on in 
a slow insidious manner ; but in either case, as far as my expe- 
rience goes, it is always accompanied by symptoms referable to a 
morbid state of the mucous membrane of the intestines. Dyspeptics, 
and individuals subject to diarrhoea, are liable to it; but it may 
also attack strong and healthy persons from the two following 
causes. A man is exposed to considerable heat, his body is bathed 
in perspiration, he experiences some degree of lassitude, and is very 
thirsty ; in this state he takes a large. draught of cold water. In a 
few hours afterwards he begins to feel uneasy, and complains of 
being unwell ; he gets shivering, nausea, thirst/and fever, and this 
fever and thirst, with bilious symptoms (as they are called), con- 
tinue for two or three days, when some morning, on awaking, the 
patient finds himself jaundiced. The same thing may happen as a 
consequence of error in diet. A person eats at supper a quantity of 
indigestible food, next day he has vomiting and thirst, and in a day 
or two more jaundice appears. I may remark here, that this indis- 
position of two or three days' standing is a very curious and interest- 
ing feature in the disease, and would seem to be connected with the 
progress of disease in the mucous surface of the stomach and 
duodenum. Jaundice from gastro-duodenitis generally occurs in 
this country under two varieties. The first is an extremely mild 
disease ; it comes on with very slight and transient symptoms of 
constitutional or local derangement; it seldom prevents the patient 

j from pursuing his ordinary avocations, and generally disappears 
without any trouble. The second variety is an extremely severe 
and frequently a fatal disease; between this and the former there 
are numberless shades and gradations. 

Let us take a case of the more severe form of jaundice. The 
cause of this, as I have already mentioned, is often the taking a 
copious draught of cold water while the body is heated by exercise, 
or eating a quantity of indigestible food. The patient is indisposed 
for two or three days before the jaundice appears ; he has nausea, 
vomiting, great thirst; loss of appetite ; he complains of burning 
heat in the epigastrium, and there is some tenderness on pressure 
over the region of the stomach and duodenum. His tongue is foul, 

| his bowels costive, his urine loaded ; he has considerable prostration 
of strength, complains of vertigo and lowness of spirits, and is con- 
stantly sighing. There is always more or less febrile disturbance; 
in some cases the fever is ephemeral, and goes off in a day or two; 
in others it continues for a much longer period. When this fever 
continues beyond the second or third day, it is to be looked upon as 

j an unfavourable sign, and you may expect that the case will be 
unmanageable and dangerous. There is another remarkable symp- 

j torn on which I have had reason generally to found an unfavour- 

| able prognosis, and this is a variation in the intensity of the 
yellowness. In some cases, you will find that to-day the counte- 

| nance and skin are much less yellow, and this is always noticed by 

! the patient, whose spirits are generally raised by the decline of the 

14 



150 



STOKES'S THEORY AND PRACTICE. 



jaundiced tint, but in a day or two it becomes as deep as ever, and 
it may go on in this way, alternating from a faint to a deep tinge, 
and vice versa. This is an unfavourable symptom ; it appears to 
indicate the repetition of inflammatory action, in the intestinal tube, 
because each increase in the depth of the yellow tinge is accom- 
panied by an increase of the epigastric symptoms. In such cases 
as this, the patient does not, as under other circumstances, shake 
off the disease and return to his usual habits ; he lies in bed, and 
though he complains of no pain, except when you make firm pres- 
sure upon the epigastrium, still he is not at all improving ; he tells 
you he is better, but he is still languid, and his appetite does not 
return. The stools are generally clay-coloured, but this is not a 
necessary consequence of jaundice ; they are sometimes yellow, and 
I have seen them of a perfectly healthy appearance. The pulse, in 
most cases where the fever is ephemeral, returns in a few days to 
its natural standard ; in some instances it is remarkably slow, and 
this state of pulse is to be regarded as an unfavourable symptom. 
Sometimes there is a slight degree of subsultus tendinum and 
delirium ; and I must observe that you are never to forget that the 
early supervention of nervous symptoms, in any form of this dis- 
ease, is always to be looked upon with suspicion. One-of the most 
alarming complications, however, of this gastro-duodenal jaundice, 
is the occurrence of coma during its progress, a symptom to which 
the attention of the profession was first strongly directed by Dr. 
Marsh. He has given several cases of jaundice, characterized by 
this symptom, the majority of which resisted all the ordinary re- 
sources of medicine, and terminated fatally. I must confess, too, 
that I have never seen a case, in which the coma was distinctly 
established, terminate favourably. You should, therefore, when 
called to treat a case of jaundice, be always on the alert, and never 
allow any bad symptom like this to steal upon you ; and it is grati- 
fying to think, that if you take this symptom in time, you will, in 
all probability, be able to overcome it. 

An extremely interesting paper on this coma, occurring in jaun- 
dice, will appear in the forthcoming number of the Dublin Medical 
and Chemical Journal, from the pen of Dr. Griffin, of Limerick. 
He gives the details of some extraordinary cases, which you will 
find well worthy of an attentive perusal. Out of four cases in one 
family, which he attended, two died, who had become comatose at 
an early period; in the other two, the affection of the brain was 
relieved by bleeding and other active measures. From this it 
would appear, that the mere supervention of coma is not necessarily 
followed by death, but that it is an exceedingly dangerous symptom 
when it comes on at an early period of the disease. It is very diffi- 
cult to give a satisfactory explanation of this. Some persons think 
that it is attributable to the action of the bile on the blood which is 
circulating in the brain. This explanation would answer very well 
if coma was a symptom of common occurrence; this, however, is 
not the case, and we must seek for some better reason. It is stated, 



JAUNDICE FROM GASTRO-ENTERITIS. 



151 



by some, that coma may be one of the consequences of the close 
! sympathy which exists between the brain and liver. Dr. Griffin 
i draws an analogy between the effects of suppression of bile in jaun- 
dice and suppression of urine in diseases of the kidneys, and thinks 
that the affection of the brain is of common occurrence in one as 
I well as in the other. This analogy, however, is incomplete, for we 
1 have no case of complete suppression of urine without fever and 
! other violent symptoms, but we have many cases of complete sup- 
' pression of bile with very slight and almost inappreciable disturb- 
j ance of the economy. It is very difficult, in the present state of 
medical science, to explain the coma of jaundice ; all we know is, 
| that it sometimes occurs, that it is a bad symptom, and must be met 
with great activity. I may mention one fact which seems to be 
strongly opposed to the analogy of Dr. Griffin. It will be proper 
to observe here, that Dr. Griffin does not advance this as an opinion, 
or advocate it as a theory ; he merely offers it as a hint or sugges- 
tion, leaving it to others to decide the question. We are not, there- 
fore, in examining this analogy, reasoning against any opinion of 
his. But with respect to this matter, the fact to which I allude is 
this — one of the worst cases of coma I ever witnessed, occurred in 
a patient who had no suppression or retention of bile ; the bile 
flowed freely into the intestines, the dejections were distinctly tinged 
with it, and yet this man had deep jaundice and intense coma. We 
are still in want of a number of facts on this point ; it is a subject 
which affords a large field for interesting inquiry, and Dr. Griffin 
deserves great credit for the philosophical and impartial manner in 
which he has brought his cases before the medical public. 
I When a patient dies of jaundice, accompanied by this comatose 
I affection, you are naturally anxious to ascertain the cause of death. 
Now what you will generally find is this: on opening the head you 
examine the brain accurately, but cannot detect any lesion of its 
substance or membranes ; you then go to the stomach, and discover 
there marks of vascularity ; you open the duodenum, and find it in 
| a state of intense inflammation. I have seen many cases of this 
| disease in which the mucous membrane of the duodenum was highly 
j engorged and almost black. It is said that this inflammation ex- 
j tends from the duodenum along the common biliary duct to the 
| liver. I am not possessed of facts to confirm this assertion, but I 
| have little doubt that, in the majority of cases, the jaundice is more 
| the result of a mere lesion of innervation of the liver, than proceed- 
| ing from any spread of inflammation along the ducts into its sub- 
! stance. Unless we can demonstrate this inflammation, it is idle to 
\ assume its occurrence. When you examine the liver, gall-bladder, 
' and biliary ducts, you generally find them in the normal state. In 
I a few cases, the ducts have been found inpervious from adhesive 
i mucus; you will see in John Hunter's works a case of this kind, 
j which occurred in a consumptive patient. You will find a great 
| number of important facts, relating to the pathology of jaundice, in 
I the commentaries upon his own pathological propositions by M. 



152 STOKES'S THEORY AND PRACTICE. 

Broussais. I would also advise you to peruse Dr. Marsh's excellent 
paper in the Dublin Hospital Reports. 

We come now to the diagnosis of jaundice depending upon 
gastro-duodenal inflammation. . In the first place, we learn from the 
history of the case that the exciting cause has been some excitant 
of inflammation in the mucous surface, the ingestion of indigestible 
aliment, or taking cold water into the stomach while the body has 
been overheated. The next thing is the supervention of fever with 
gastric symptoms, and these being followed, in two or three days, 
by an attack of jaundice, without any of the ordinary signs of 
hepatitis. Here we have a disease excited by taking cold water 
while the body is heated, or by indigestible food, preceded by febrile 
disturbance with gastric symptoms, and unaccompanied by the 
symptoms or signs of hepatitis. When this combination of circum- 
stances occurs, you make your diagnosis with great certainty, and 
set it down as jaundice depending on inflammation of the stomach 
and duodenum, and treat it accordingly. There are but two forms 
of jaundice accompanied by symptomatic fever ; the one under con- 
sideration, and that which is the consequence of hepatic inflamma- 
tion, or other disease. It might be supposed that the tenderness of 
the epigastrium was caused by an affection of the liver, but by 
making an accurate examination you will be generally able to dis- 
criminate with certainty. You will find that the pain is less than 
that of acute hepatitis, that strong pressure gives pain, not in the 
region of the liver, but in that of the duodenum ; you can ascertain 
by a manual examination, and by the pleximeter, that there is no 
enlargement of the liver, that there is no remarkable dulness on 
percussion at the low 7 er part of the chest on the right side, and when 
the fever is ephemeral, this will furnish you with much valuable 
assistance towards forming a correct diagnosis. 

With respect to the treatment of this form of jaundice, in mild 
cases, where there is little or no fever (for fever is to be taken as a 
test of the severity of the disease), the patient very often gets well 
without any treatment, and the jaundice, after lasting a few days or 
weeks, goes off spontaneously. In all such cases, a regulation of 
diet, keeping the bowels open by mild laxatives, and prohibiting 
wine, spirits, and other stimulants, will be found, in general, suffi- • 
cient to remove all the symptoms. I wish, however, to impress j 
upon you that it is of the utmost importance to cut short this dis- 
ease as soon as possible. There is no use in letting it get ahead 
of you ; and in every case where the symptoms are in any degree 
acute, and there is a degree of fulness and tenderness over the 
epigastrium, you will be culpable, if you omit to apply leeches over i 
the stomach and duodenum, and prescribe iced water, and every - 
other means calculated to remove inflammation. If you allow it to 
go on to a certain length, if you allow fever to progress, and coma 
to supervene, you will not be able to manage the case so easily. 
Never, then, omit the application of leeches the moment you have t 
ascertained the existence of decided inflammation. Keep your 1 

■ Jm 



JAUNDICE FROM G ASTRO-DUODENITIS. 



153 



i patient's bowels open by enemata, or by mild saline laxatives, regu* 
j late his diet carefully, prohibit all stimulants, and he will generally 
do well. 

Many persons are in the habit of prescribing mercury in this dis- 
ease. From my own experience I cannot say whether this is right 
or wrong ; but I can state that I have seen a great many cases get 
j well without it. But in cases where the symptoms are obstinate, 
I and the stools continue white, I think you would be justified in 
j giving mercury, even so far as to produce salivation. I must 
! remark to you, however, that I have seen two cases in which it 
was found impossible to produce the free action of mercury in 
I patients labouring under this disease. The exhibition of small 
; doses of cream of tartar, two or three times a day, made into an 
! electuary with some mild confection, I have found to be an excellent 
i remedy in the treatment of this affection. In my lecture on dysen- 
tery, I mentioned some facts which go to prove that this remedy 
seems to have great power in bringing down bilious discharges. In 
! this form of jaundice I found cream of tartar extremely useful, and 
I its exhibition is unattended with danger. 

Now suppose you should meet with a case in which coma appears 
, as an early symptom, what should your line of treatment be ? 
Here you have to deal with a very threatening symptom, which, if 
neglected for any time, will, in all probability, bring on a fatal ter- 
mination. You should, therefore, on its first appearance, meet it 
| with a corresponding activity ; you should immediately have the 
head shaved, apply leeches behind the ears, blister the nape of the 
neck, and act smartly on the bowels by laxatives. It was by such 
treatment as this that Dr. Griffin saved his patients. 

I wish here to make some observations on a very remarkable 
form of gastro-duodenitis, which was almost epidemic in this country 
some years ago, at least it occurred during the existence of an 
epidemic fever, and we had at that time a great many cases of it in 
the hospital. It is a curious fact that the majority of these seemed 
to bear a distinct resemblance to the yellow fever of warm climates. 
This will appear somewhat extraordinary ; but, when you have 
heard a statement of the facts, you will be inclined to think that 
these cases were nothing more or less than so many instances of 
the malignant yellow fever of the tropics. 7 I shall read for you an 
1 account of the symptoms, as they were observed in numerous cases 
under the care of my colleague, Dr. Graves, and myself, in the 
i Meath Hospital 

! In the great majority of cases this disease was preceded by fever; 
j in fact, all the patients who exhibited this form of jaundice had been 
i admitted as fever patients. After a longer or shorter period, with- 
| out any premonitory indications, symptoms of intense irritation of 
| the digestive tube set in, and advanced with a fatal rapidity. Most 
I of the patients vomited frequently ; there was great tenderness of 
! the epigastrium, and over the region of the small intestine; the 
! tongue became black and parched ; there was a violent pain in the 

14* 



154 



STOKES'S THEORY AND PRACTICE. 



belly, and a spasmodic affection of the abdominal muscles, which 
felt hard and knotted, and to which the nurses gave the name of 
twisting of the guts, a name which singularly agreed with the 
numerous intussusceptions found along the course of the small 
intestine after death. This state of suffering continued from one to 
four hours, and then the body became all over suddenly jaundiced. 
Then came another train of symptoms. With intense and universal 
jaundice, the patients exhibited also extreme restlessness, tossing 
their arms about, and regarding their attendants with a look at once 
expressive of nervous suffering and despair. Some raved, had 
trembling and convulsive fits, and were totally unconscious of 
everything passing around them ; others preserved their intellect 
to the last, but they had depicted in their countenances an agony 
and a despair which I shall never forget. General spasms were 
frequently observed ; and many, on attempting to swallow, had 
spasms like those of hydrophobia. There was great irritability of 
the stomach ; many vomited frequently, and in some cases the mat- 
ter ejected bore an exact resemblance to coffee-grounds. The 
pulse became low and fluttering, the extremities cold, the face pale 
and shrunken, and in some the nose assumed a purple colour, 
giving to the patient a truly horrible appearance. This change in 
the colour of the nose was preceded by extreme paleness; the part, 
at first, appeared as if it had been frost-bitten. Broad patches of a 
wax-like whiteness, elevated a little above the level of the skin, and 
somewhat resembling urticaria, having the same temperature as the 
rest of the body, were found on the following day to assume a red- 
dish colour ; and on the third day the redness was converted into 
dark purple. The toes were affected in a similar way ; and in some 
of these cases the parts so affected sloughed and were thrown off. 
There is at present in this city a women who lost the ala of the 
nose, and one of the toes, in this manner. 

The phenomena observed on dissection were equally remarkable. 
Though the tenderness of the epigastrium was very great, there 
was no trace of peritoneal inflammation; neither was there, in any 
case, inflammation of the liver, and the gall ducts icere found to be 
pervious in every instance. The mucous surface of the stomach, 
and duodenum, and ileum, were found in every case to present 
intense marks of inflammation ; there were numerous intussuscep- 
tions along the course of the ileum, and the spleen was found to be 
large, soft, and pultaceous. There was no evidence of inflammation 
of the brain ; but in the ventricles, and at the base of the brain, there 
was in some cases an effusion of yellowish fluid, and the membranes 
had a faint tinge of yellowness. In one case I found a remarkably 
dry state of the arachnoid. In one severe case there was a good 
deal of a substance resembling coffee-grounds in the stomach, and 
the mucous membrane w T as soft and disorganized. 

All the phenomena of this disease, the gastro-intestinal inflam- 
mation, the yellowness of skin, the enlargement and softening of 
the spleen, the rapid fatality and excessive prostration, seem to point 



JAUNDICE FROM G ASTRO-DUODENITIS. 



155 



out a strong analogy between it* and the yellow fever of warm 
j climates. In the writings of Rush and Lawrence, you will find 
I that their description of the phenomena, observed on dissection, 
would in a great degree answer for those of the cases which I have 
detailed. I may mention here, too, that in our cases the mortality 
| was severe. We lost the first sixteen cases ; and it was not until 
j we fully ascertained the nature of the disease by dissection, that we 
j began to save these patients. Then, by free depletions, copious 
I applications of leeches to the abdomen, and the bold use of calomel 
j and opium, we succeeded in a great number of cases. In some 
j cases death took place in four, in others in six hours ; in a few it 
j was more prolonged. There is no epidemic on record in this city 
j in which the same symptoms, and the same rapid fatality, were 
j observed. 

With respect to the analogy between this disease and yellow 
fever, it appears that in the latter affection the yellow colour depends 

j upon the presence of bile in the blood. This is one point. Again, 

j from the most accurate descriptions which have been given of the 

j morbid appearances of yellow fever, it appears that in the majority 
of cases the liver has been found healthy ; here is another point. In 

j yellow fever, also, inflammation of the stomach, duodenum, and 
intestines, is a matter of almost universal occurrence, as you will 
find by examining the works on yellow fever.* In our cases we 
had all these circumstances; we had extreme tenderness of the 

| epigastrium, and inflammation of the stomach, duodenum, and 
intestines ; and in one severe case we had black vomit. All these 
circumstances, combined with the fatality, seem to prove that the 

j cases which were under treatment in the Meath Hospital, during 
the epidemic of 1826-27, bore a very striking resemblance to that 
species of fever which is supposed to exist only in warm climates. 
It is probable that if yellow fever should appear intemperate coun- 
tries, it would exhibit itself in the form of gastric fever, with some 

! cases only of yellowness. Indeed, it seems to be now very gene- 

* [The very carefully conducted autopsic examinations made by M. Louis on a 
j number of the bodies of those who died of yellow fever, at Gibraltar, in 1828, 
j lead to new conclusions on this subject. The lesions peculiar to, or nearly peculiar 

to, yellow fever, are, M. Louis thinks, a red or black matter found in the 

digestive canal, and an alteration in the appearance and structure of the liver. 

The first, or the red and black matter, is evidently that which the author calls the 

materials for the hemorrhagic vomitings in the disease. It was found in the 
i stomach in about three-fourths, and in the intestine in two-thirds, of the subjects ex- 
i amined. But the most remarkable and the most constant lesion, that which M. 

Louis regards as the essential anatomical character of yellow fever, is the 
i change in the liver. In all cases of the disease, the colour of this organ was 
| changed to that of a light yellow, or straw colour. " Sometimes it exhibited a 
J fresh-butter, or straw, or coffee and milk hue ; at other times, a yellow, or gamboge, 
j or mustard, or orange, or, finally, an olive colour." There was at the same time a 

very evident dryness of the hepatic tissue, and more commonly an increase than 
j diminution of its cohesion. M. Rufz, who had, recently, opportunities of seeing 

the yellow fever at Martinique,_found similar lesions to those noticed by M. 
| Louis.— B.] 



I 



156 



STOKES'S THEORY AND PRACTICE. 



rally admitted, that yellow fever has nothing peculiar in it; that it 
is the maximum of bilious or gastric fevers. We find that in pro- 
portion as we approach the warm latitudes, the digestive mucous 
membrane appears to take on a greater susceptibility of disease. 
Between the tropics it would seem as if morbid actions were chiefly 
thrown upon the viscera of the abdomen. Europeans, who have 
resided there for any length of time, acquire a yellow tinge, and 
many of them suffer from intestinal and hepatic inflammations. If 
we go northward, we find the case to be the reverse; as we ap- 
proach the colder latitudes, we find the mucous membrane of the 
digestive tube acquires a greater degree of tone and vigour, that it 
is less susceptible of disease, and can bear much greater stimulation. 
The inhabitants of warm climates use a large proportion of vege- 
table food ; they seldom indulge in the use of animal food or spirits. 
The Hindoo lives on rice, the Arab on dates and milk. But, if we 
go northward, we find the natives habitually using stimulating food 
and drink with impunity ; indeed, it is wonderful to think what 
vast quantities of flesh, animal oil, and other stimulants, the stomach 
of an Esquimaux or Kamschatkan will bear without injury. 
There is no doubt that warm climates predispose to inflammatory 
affections of the digestive apparatus, and this seems to connect _ 
yellow fever with the ordinary form of gastro-duodenitis, accom- 
panied with jaundice, or, in other words, a little more extent, a 
greater degree of intensity, and we may have the jaundice of this 
country converted into yellow fever. And it is fair to conclude 
that the typhus icterodes of temperate countries owes its danger 
not to the mere circumstance of jaundice existing, but to the greater 
degree of secondary gastro-enteritis which has produced that 
jaundice. 

I shall now draw your attention to some other forms of jaundice. 
One of the most important of these is, that which arises from the 
obstruction of the biliary ducts by calculi. It would be foreign to 
my purpose to enter into any discussion with respect to the forma- 
tion of gall stones in a course of lectures like this; I shall therefore 
refer you, for information as to their history and composition, to 
the various treatise on animal chemistry. What we have to con- 
sider at present, are the symptoms of the disease, the habit of body 
in which it is found to occur, and its mode of treatment. You see 
on the table numerous preparations of the various forms of this 
disease. 

Gail stones are more commonly observed after the age of forty or 
fifty than before these periods ; they are very frequently met with 
in persons of sedentary habits, and hence women are more subject 
to them than men. The}' are also liable to occur in persons who 
eat highly-seasoned indigestible meats, and take little or no exer- 
cise. It is stated that in England five-sixths of the cases of gall 
stones occur in females. I do not know whether this proportion 
be exact, but the fact is established that they are more common in 
females then men. Biliary calculi may be found in three different 



JAUNDICE FROM GASTRO-DUODENITIS. 



157 



situations, either in the substance of the liver, or plugging up the 
biliary ducts, or filling the gall-bladder. Here is a preparation, 
exhibiting the gall-bladder almost obliterated by the pressure of a 
number of those calculi within its cavity. Here is another speci- 
men. You see the gall-bladder is contracted, and nearly filled up 
with biliary calculi ; it also appears to be atrophied and reduced in 
size. Here is a remarkable specimen. You observe the gall-blad- 
der, which is rather large, is completely filled with a vast calculus; 
its coats are also thickened, probably the result of inflammation. 
| Here is another preparation of the gall-bladder, containing two 
moderately-sized calculi. 

Gall stones, when lodged in the substance of the liver, or in the 
gall-bladder, may remain for a long time, and accumulate pro- 
digiously, without producing jaundice. This has been frequently 
i proved by the fact, that on opening the bodies of persons who have 
not had during life the slightest symptom of jaundice, the gall- 
bladder has been found completely rilled up with these productions. 
But when any cause determines the passage of one of these bodies 
; into the ducts, and that it is too large to pass freely, then the symp- 
toms of icterus begin to make their appearance. We do not know 7 
what it is that produces the attempt to discharge small biliary cal- 
culi through the ducts, but it is during this process that the dread- 
ful symptoms of what has been by some called hepatic colic are 
observed, and supervening on these, the rapid occurrence of jaun- 
I dice. Under such circumstances, a train of phenomena presents 
itself, very different from that which characterizes the jaundice 
depending on inflammation of the stomach and duodenum. The 
patient is suddenly attacked with violent pain in the epigastrium 
and right hypochondrium. The stomach sympathizes, and we have 
nausea, cardialgia, and vomiting; the patient's sufferings are dread- 
ful, and he refers his pain to the region of the gall-bladder. The 
abdominal muscles are thrown into spasmodic contractions, there 
are often convulsions and fainting fits, the extremities are cold, the 
body x is bathed in perspiration, and the pulse is often hard and con- 
tracted, but seldom accelerated. This is a very remarkable symp- 
tom. Heberden says, that the pulse not being in quickness above 
the standard of health, with a sudden attack of pain in the region 
of the epigastrium, are diagnostics of this affection. " I have 
seen," says he, "a patient in this disease rolling on the floor in a 
state of violent, agony, which I could not allay with nine grains of 
opium, and yet the pulse was as tranquil as if he was in a calm 
sleep." I can confirm the truth of this observation from my own 
j experience. Here are the diagnostics ; the pain is more intense 
than that which attends any form of inflammation, and yet the 
pulse is perfectly quiet; it occurs in persons not generally subject 
to spasmodic attacks ; it is not preceded by constitutional symptoms ; 
and is rapidly followed by jaundice, and absence of bile in the stools. 
Under these circumstances you may make a certain diagnosis. 
Sometimes a tumour is formed in the right hypochondrium y 



158 STOKES'S THEORY AND PRACTICE. 



which rises above the edge of the liver, and gives a feeling of dis- 
tinct fluctuation, marking the situation of the distended gall- 
bladder. In such cases as these, the calculus is in the common 
duct, and the bile descends into the gall-bladder, from which it 
cannot escape, thus causing the distension of that organ. This 
may go on until the distension becomes so great as to increase the 
size of the gall-bladder to such a degree that, in some cases, it has 
been known to contain a pint of fluid; and cases have occurred in 
which it has burst, and effused its contents into the peritoneum, 
causing violent peritonitis and death. This termination, however, 
is fortunately of very rare occurrence. I believe that some of the 
cases in which rupture occurred, were those in which an emetic 
was given; and hence it is that many practitioners are afraid to 
give an emetic where this state of the gall-bladder has been ascer- 
tained, or is strongly suspected. 



LECTURE XIV. 

Diagnosis of jaundice from biliary calculi — Proof of the passage of the calculus — Indi- 
cations of treatment — Rupture of the gall-bladder after the use of emetics — Spasmo- 

( die jaundice — Treatment of spasmodic jaundice — Discharges of fatty matter — Re- 
searches of Drs. Bright and Elliotson — Connection with malignant disease examined 
-^Source of fatty matter. 

We were occupied at our last meeting, in considering the symp- 
toms of that disease in which there is a formation of what are termed 
biliary calculi ; the passage of these into the common biliary duct; 
the possible strangulation of the duct for some time, and the conse- 
quent production of jaundice. I described the symptoms of this 
disease as consisting in a sudden and violent attack of pain in the 
region of the gall-bladder, succeeded sooner or later by the pheno- 
mena of jaundice, and in the generality of cases occurring without 
fever. Between these violent attacks the patient sometimes has in- 
tervals of complete ease ; at other times a gnawing sensation con- 
tinues in the original situation of the pain. It is remarkable, how- 
ever, that a patient may have an interval of perfect ease between 
the fits, somewhat similar to the calm which occurs during the 
pains of labour. The occurrence of this cessation of intense suffer- 
ing has been attributed to the passing of the stone into the duode- 
num ; this, however, is by no means certain. The idea generally 
entertained upon this matter is that each attack of pain corresponds 
with the passage of a stone. How far this notion may be true I 
cannot decide ; but this I shall impress upon your attention, that 
the mere subsidence of pain is no proof of the removal of the disease, 
unless bile is discharged by stool or by vomiting ; but when such a 
discharge coincides with the cessation of pain, you may be sure that 
the obstruction has been overcome for the time. I need not remark 
to you that the smaller the calculus is, the greater the facility with 



[JAUNDICE FROM BILIARY CALCULI. 159 

| which it will be discharged. You will find in some cases that the 
efforts which nature makes to remove one of these concretions are 
quite unavailing; it lies in the gall-bladder or duct, and there re- 
mains impacted. Here its presence sometimes excites inflamma- 
I tion, lymph is thrown out, and the duct becomes permanently 
I closed : in other cases it has been found to make its way into the 
duodenum by ulcerative absorption, and is thus discharged. 

The size of biliary calculi is various. Generally speaking, their 
dimensions are similar to those which you see before you ; but there 
are many cases on record of very large ones having been dis- 
charged. In the twelfth number of the Medico-Chirurgical Trans- 
j actions, Dr. Brayne gives an instance of one passed, which was 
three inches long and three and a quarter in circumference. I may 
| however mention, that there is a source of doubt connected with 
| this case. It is possible that the calculus in this instance was 
nothing more than one of those fatty covered secretions which 
are found in the intestinal tube, and which have nothing to do with 
i the gall-bladder or its ducts. As it is my intention to return to 
J this subject, I shall here only observe, that fatty matter has been 
frequently discharged in hard .as well as soft masses, that it some- 
times cuts like a biliary calculus, and that, it may be difficult for a 
mere physiologist to distinguish concrete masses of this kind from 
gall stones. 

The passage of a biliary calculus does not of necessity imply the 
occurrence of jaundice ; if it passes without difficulty there is none ; 
if it happens to become impacted, then jaundice is sure to follow. 
It is a curious fact, that of this form of jaundice cases have occurred 
in which the flow of bile into the digestive tube has been obstructed 
for more than a year, and yet a recovery took place. 

Permit me now to rehearse the diagnosis of jaundice from biliary 
calculi. Sudden and violent pain in the region of the gall ducts, 
increased by pressure, but generally unaccompanied by accelera- 
tion of pulse or fever, coming on in a person not subject to spasmo- 
dic attacks, and speedily followed by jaundice. This is the diag- 
nosis. In most of the cases described in books, and, I believe, in 
the majority of instances, you will find the disease to exist without 
febrile symptoms; but it is also true that it may be complicated 
with febrile disturbance, and under such circumstances you should 
be apprehensive of inflammation in the biliary ducts or duodenum. 
The importance of this will appear when you come to consider the 
treatment. 

Now, suppose you are called to attend a case of this kind. A 
person of sedentary habit, who indulges in highly seasoned food 
! and takes no exercise, gets, a sudden attack ; he lies, perhaps on 
I the floor, writhing in agony ; he is beginning to exhibit the yellow 
tinge of jaundice ; he refers his pain to the region of the gall- 
bladder ; his pulse, however, is quiet, and he has no evident symp- 
toms of fever. Here the nature of the disease is manifest, and the first 
thing you have to consider is, what are the indications of treatment. 



160 



STOKES'S THEORY AND PRACTICE. 



These are obviously threefold. The first is to guard against in- 
flammation ; for you are aware that inflammation may take place, 
and besides, the higher the irritation and (if I may so term it) the 
spasm of the gall ducts are, the greater will be the difficulty in 
passing the stone. The next thing is to allay spasmodic pain. We 
know that this pain is principally spasmodic, or nervous, because it 
is always more sudden and violent than that which attends common 
inflammatory action, and, moreover, it is commonly uncomplicated 
with symptoms of inflammation. The third indication is to adopt 
measures to favour the passage of the stone. Now these three in- 
dications, but more particularly the second and third, are, as you 
may perceive, reducible to one form of treatment. Whatever will 
relieve pain and spasm will assist in favouring the passage of the 
stone. If, then, you happen to meet with a case of this affection in 
a strong robust constitution, where the pain is violent and is aggra- 
vated by pressure, and particularly where there is any sign of 
febrile disturbance in the system, 1 would advise you to bleed such 
a person immediately. Not that you have to combat actual inflam- 
mation, but because you have to prevent the liability to it, and be- 
cause, in using the lancet, you are employing a most powerful anti- 
spasmodic. The next thing of importance, in severe cases, is the 
application of leeches over the region of the gall-bladder, and the 
same remarks apply to leeching as to venesection. You are not to 
suppose that the application of leeches will cure the disease ; but 
you may be sure that it will assist materially in allaying spasm, and 
favouring the passage of the calculus. The bowels should be freely 1 
acted on by purgatives and enemata ; you may give a brisk purga- 
tive by the mouth, and at the same time a purgative enema. After j; 
the bowels have been opened, the only thing which you can rely 
upon for giving relief is opium, and that in full doses. I have seen I 
several patients labouring under this disease who appeared to me* it 
to be maltreated. The different measures for procuring relief || 
were certainly put into practice, but not in a regular or proper 
manner. They first got a dose of opium, then a purgative, and 
lastly were blooded. If you have a case of this kind to treat, bleed 
first, then leech, next employ purgatives, and when you have 
emptied the bowels, have recourse to opium. I have never em- ti 
ployed the anodyne injection in this disease ; but, reasoning from 
analogy, I am inclined to think that it would prove serviceable, and 
I am aware that it has been employed with effect in that form of j; 
jaundice which depends upon hysteria. The tobacco injection also 
seems to have strong claims to our notice, and in this disease i 
must prove extremely useful, from its powerful effect in reducing d 
spasm. 

There is a difference of opinion with respect to the employment 
of emetics. The object of their exhibition is to force the calculus J 
through the ducts, by the shock given by the sudden and violent 
contraction of the abdominal muscles, and also to relieve spasm, by ij 
their subsequent relaxing effect. Some practitioners of high au- A 



JAUNDICE FROM BILIARY CALCULI. 



161 



| tbority, however, state that this practice is not unattended with 
j danger, and give cases of rupture of the gall-bladder after the exhi- 
| bition of an emetic. Such an accident as this would be very 
; likely to injure for ever the character of a professional man. I am 
sure the practice, in some cases at least, is dangerous. A distin- 
j guished medical friend of mine has related to me the particulars of 
' a case of this kind, in which the exhibition of an emetic was fol- 
| lowed by rupture of the gall-bladder and fatal peritonitis. In this 
instance the case was not so deplorable, so far as the patient was 
j concerned ; he was labouring under extensive disease of the liver, 
and only exchanged a lingering for a sudden death ; but this fur- 
| nishes no excuse for a medical practitioner. If I were to hazard a 
conjecture, I would say that emetics can be employed with safety 
, only in the early stage of the disease, ivhen there is no obstruction 
, from organic disease; for the longer the jaundice has lasted, the 
greater is the chance of obstruction from organic disease. Again, 
you should never use them where there is evidence of a distended 
gall-bladder. If you can feel the tumour formed by the distended 
gall-bladder, in the right hypochondrium, you may be sure some- 
thing has been going on for a long time, and you should be cautious 
in giving an emetic. Never use it then where you can feel a tu- 
mour in the region of the gall-bladder. If you give it at all, give it 
in the early stage, and after premising venesection, leeching, and 
the use of the tobacco injection. I had almost forgot to mention 
! that very signal advantages accrue from the use of the warm hip 
bath in this disease. I have seen cases in which the most extra- 
ordinary relief was obtained by applying twelve leeches over the 
region of the gall-bladder, and then placing the patient in a hip bath. 

Sometimes it happens that the symptoms return again and again. 
Here you cannot repeat the venesection ; you must employ leeches, 
the hip bath, warm fomentations, opium, and everything calculated 
to relieve pain and spasm. Watch your patient carefully, guard 
against inflammation, and' if any inflammatory symptoms of the 
duodenum arise (but this is rare) "take proper measures to obviate 
them. 

A few words now with respect to what has been termed spas- 
modic jaundice. This form of the disease occurs independent of 
inflammation of the stomach or duodenum, and independent of dis- 
ease of the ileum, brain, or liver. It appears to be an essentially 
spasmodic disease, but the situation of the spasm has not as yet 
j been accurately determined. It is supposed to exist, either in the 
I gall-bladder, or in the biliary ducts, or in the duodenum. If the 
biliary ducts and gall-bladder do not possess muscular fibres, we 
must place it in the duodenum ; but whatever may be its seat, it 
presents the characters of a spasmodic disease. It seems to be 
excited by the same cause, and yields to the same treatment as 
other spasmodic affections. It generally occurs in hysterical 
females, and in hypochondriac and nervous persons, and disappears 
under treatment calculated to allay nervous excitement. Its exciting 

'15 




1C2 STOKES'S THEORY AND PRACTICE. 



causes seem to be chiefly sudden and violent mental emotions, or the 
taking of a quantity of indigestible food ; and it frequently terminates 
by the discharges of flatus upwards and downwards. It resembles, 
in a certain extent, the last-mentioned form of jaundice, but differs i 
in two particulars ; first, the pain is relieved by pressure, which 
generally increases it in the former species. Dr. Pemberton, in his 
Treatise on the Diseases of the Abdominal Viscera, dwells strongly 
on this point. The second peculiarity is, that in this disease the 
attack is more sudden. In the case of jaundice from gall stones, 
the patient has some degree of pain and uneasiness before the vio- 
lent symptoms appear; but in this form they exhibit themselves in 
a sudden and unexpected manner. The disease, too, is accom- | 
panied with hysterical or convulsive symptoms, and there is some- 
times a copious flow of limpid urine. All these circumstances are 
important in forming a correct diagnosis. 

The best treatment for this spasmodic jaundice is, after acting on 
the bowels by warm purgatives, to use fetid enemata, and prescribe a 
mixture composed of ether, castor, and ammoniated tincture of 
valerian and opium, which are of the greatest use when the bowels 
have been opened. In this form, as well as that which we have 
been lately considering, the fact is, that if you expect any good 
from opium, you must not give it until the bowels have been 
opened. Opium and antispasmodics have, I am convinced, often 
lost their character for utility, from being given at a time when the 
exciting causes of disease are still present in full energy ; and the 
failure of these powerful auxiliaries is to be attributed to the neglect 
of proper measures for reducing intense irritation. In the spasmo- f 
die jaundice, tobacco injections would be likely to produce bene- j 
ficial effects. Generally speaking, however, you will not find it 
necessary to have recourse to such a vigorous remedy, as the 
disease is most commonly observed in delicate females, and yields ) 
readily to milder treatment. Indeed, it will often disappear spon- ; 
taneously, and without any apparent cause. I 

The last form of this disease which we have to consider, is jaun-. 
dice connected with an affection of the brain; and this is a very | 
interesting and curious subject. I shall not, however, enter upon 
it at present, as I intend to reserve my observations on this point j 
until we comes to treat of diseases of the nervpus system. I have ! 
alluded to this variety on a former occasion, and referred you to 
Dr. Marsh's paper on jaundice in the Dublin Hospital Reports, in 
which you will find several cases of it which came on as the result i 
of disease in the head. Broussais admits that it is dependent on 
and secondary to cerebral disease ; but he thinks there is another 
link in the chain of connection, and that this is duodenitis. He 
believes that we have irritation, first in the brain, next in the duo- i 
denum, and then jaundice. Several practitioners of great authority, 
on the other hand, assert that the cerebral affection produces jaun- 
dice at once, without the intervention of duodenal inflammation. 
In the present state of medical science we cannot determine this i 
point. 

* ^ • * J 



JAUNDICE FROM BILIARY CALCULI. 



163 



A few observations now with respect to the discharge of fatty 
matter from the bowels. The reason why I introduce the subject 
here is, because it has been frequently observed in connection with 

jaundice and disease of the upper portion of the digestive tube. In 
the last number of the Medico-Chirurgical Transactions, a great 
mass of interesting matter has been published on this subject 
by Dr. Bright, Dr. Elliotson, and Mr. Lloyd. I shall give you a 
short analysis of these papers ; and I wish to impress this upon 
your recollection, that when you go into practice the study of this 
affection would form a subject worthy of your investigations ; and 
that any attempts on your part to clear up the difficulties which 
complicate this singular form of disease will be advantageous to the 
cause of science. 

Dr. Bright gives three interesting cases of this disease. In these 
the discharge was in the form of oil or semi-concrete matter — it 
floated on the top of the fseces, and had a fetid odour. There was 
also in these three cases a remarkable similarity in the pathological 
phenomena. The first case exhibited symptoms of jaundice, dia- 
betes, enlarged liver, and discharge of fatty matter ; on dissection, 
the liver, pancreas and duodenum were found diseased. The 
second presented symptoms of jaundice and disease of the liver, in 

i addition to the fatty discharge ; on dissection the liver was found 
healthy, but there was a similarly diseased condition of the duo- 
denum and pancreas; there was malignant disease in both. Nearly 

i the same symptoms were observed in the third case, and after death 
disease was found in the pancreas and small intestine, and the pylorus 
was in a state of extensive ulceration. In all there was chronic 

i disease of the pancreas and duodenum terminating in jaundice, from 

I obstruction of the gall duct, and accompanied by discharges of fatty 
matter from the bowels. Here are three cases in which there is an 
extraordinary similarity in the symptoms and pathological appear- 
ances. Dr. Bright is inclined to think that these discharges may 
be connected with disease of the pylorus and duodenum, but par- 
ticularly with malignant affections of the pancreas, and gives the 

I partic ulars of some cases, in which disease of the pancreas was sus- 

| pected, and in which, from the absence of this symptom, he was 
induced to give a contrary opinion, which, on dissection, turned out 
to be correct. 

Mr. Lloyd's case resembles those detailed by Dr. Bright, inas- 
much as it presented the phenomena of jaundice with obstruction 
of the gall ducts, disease of the head of the pancreas, and contrac- 
| tion of the duodenum. So that you see we have here four cases in 
, which there was disease of the duodenum and disease of the pan- 
1 creas, together with the occurrence of jaundice. I may, however, 
| mention one fact, which you should be acquainted with ; in Mr. 
i Lloyd's case the pancreatic duct was found to be obstructed by 
| calculi. 

I Dr. Elliotson commences his paper by alluding to that peculiar 
j substance called ambergris, which is frequently washed ashore by 
I the tide in several countries, and which is supposed to be a morbid 



164 



STOKES'S THEORY AND PRACTICE. 



production from the intestinal canal of the physeter macrocepha- 
lus t or spermaceti whale. The quantity found in the intestinal 
canal of this animal is said to be enormous, and instances are 
mentioned, in which this substance was found to amount to 182 lbs. 
in the body of one of these animals. Dr. Elliotson proceeds to give 
cases from the records of medicine and from his own experience, 
in which a fatty discharge took place in the human subject. Of 
this he quotes cases from Meelenbrochus and Maebius in the Ephe- 
merides, but one in particular from the works of Fabricius Hildanus, 
which I shall briefly recount. " A pious matron of Hilden had 
been for. a long time subject to severe pain in the stomach, which 
became at length much worse, when one day the pain extended all 
over the abdomen, and after very severe pain and suffering, she 
discharged about three pounds of fat, which was of a pure quality, 
had no smell, and was preserved by her for many years." This 
woman recovered perfectly. Dr. Scott, of Howick, mentions the 
case of a servant girl who had been treated with purgatives and 
injections, under the supposition that her disease was colic, and 
who, after two or three days' suffering, discharged a quantity of 
fatty substances, about the size of nuts, beans, and peas, which 
burned like fat when thrown into the fire ; this patient also re- 
covered. Dr. Babington gives another case, which had been 
mentioned to him by Sir E. Home, in which we find that a lady 
who had been suffering, as it was supposed, from gall stones, 
happening to take castor oil draughts to open her bowels, passed a 
quantity of fatty matter. Another case is detailed by Mr. Howship, 
where a lady who had been attacked with pain, jaundice and 
fever, passed a quantity of this substance with the subsidence of I 
those symptoms. The fatty matter in this case was discharged i 
after the lady had taken a pint of olive oil, upon the recommenda- \ 
tion of Dr. Simpson of New Malton. Dr. Turner, of St. Thomas's j 
Hospital, mentions the case of a" female who laboured under an j 
hysterical distension of the belly, and who passed quantities of this j 
substance, specimens of which are preserved in the Hunterian i 
Museum." 

Sometimes these fatty discharges are found in the concrete, some- 
times in the semi-fluid form. Dr. Elliotson mentions the case of a > 
patient who had phthisis, diabetes, and discharge of fatty matter ; 
thus he was at the same time passing fatty substance, large quanti- 
ties of saccharine urine, and spitting up pus and softened tubercular r 
matter. Between all these, and the agonising pain which he suf- 
fered, he became in a short time completely exhausted and sank { 
rapidly. The fatty matter discharged in this case was shown to J 
Dr. Prout and Mr. Faraday, and Dr. Prout stated he could not- 
distinguish it from human fat when heated. Tulpius is quoted by ' 
Dr. Elliotson as relating a case where fat- was discharged from • 
the bowels and bladder. Here is the quotation: — "But what do \ 
we say of Margaret Appelmania, an innkeeper, who, in her seven- I 
treth year, passed precisely the same fat, both from the intestines 1 
and the bladder, and likewise without fever, emaciation, or colli- 



JAUNDICE FROM BILIARY CALCULI. 



165 



quative excretion. Towards the close of the disease, however, she 
did become feverish, and, in consequence, so emaciated, that death 
found her little else than a juiceless dried up corpse." A case* 
similar to this was communicated by Mr. Pearson to Dr. Elliotson. 
The symptoms w 7 ere suppression of the biliary secretion, and a 
j copious discharge of oil from the bowels and bladder, which, it is 
j stated, formed good soap when mixed with alkali. Dr. Prout has 
; observed fatty matter passed with the urine, and considers this 
I symptom as an indication of the probable supervention of malig- 

I nant disease of the kidneys and bladder. The last case is from the 
. Annali Universalis which is quoted by Dr. Johnson in the Medico- 
j Chirurgical Review for July. In this case the patient, after fasting 
; for a considerable time, took a quantity of indigestible food. On 
i the evening of the same day he had an attack of vomiting ; at first 
i blood was thrown up, and then he ejected this fatty substance to 

: the enormous amount of thirty pounds. There was, in this 
instance, a sudden and extraordinary emaciation; the patient was 

II so reduced in the space of a few hours, that the skin hung in loose 

I folds about him. He recovered in twenty days; but with great 
loss of bulk. 

I Let us inquire now what is the nature of-this symptom. Is this 
fatty matter a morbid secretion from the liver, from the pancreas, 
from the mucous membrane of the stomach, or from the intestines 1 
There are facts to show, that in certain cases this disease cannot 
| be explained by a reference to any of these circumstances. It 
seems plain, too, that Dr. Bright's suggestion of referring it to ma- 
lignant disease of the duodenum and pancreas, and the diagnosis 
which he would seem to found upon it, cannot stand here ; for the 
symptom upon which he attempts to establish a diagnosis — a dis- 
charge of fatty matter — occurs in persons who have recovered from 
the disease. We cannot suppose that they have been labouring 
j under malignant disease of the duodenum and pancreas when they 
have recovered ; and that a recovery may take place is proved by 
Dr. Elliotson's cases. It is quite probable, however, that if the 
irritation, or whatever it be that produces this discharge, should 
continue, it may bring on fungoid and malignant disease ; but that 
j the discharge of fatty matter is significant of the actual existence of 
such a condition is not borne out by these facts. Well, are we to 
look upon this discharge as a secretion from the liver? I think 
we cannot, because we have seen that in Dr. Bright's three cases 
the biliary duct was obstructed by disease of the duodenum and 
i pancreas. I may mention, too, that in some cases where a dissec- 
j tion was made, the liver was found perfectly healthy, and the gall- 
bladder in its normal condition, full of pure bile. Taking this and 
! the foregoing fact into consideration, we have proofs that this fatty 
| substance, in some cases at least, cannot come from the liver. Does 
i it proceed from the pancreas 1 It would more naturally come from 
j the liver than the pancreas, for the liver does actually secrete a 
j certain quantity of fatty matter; but there is no substance of this 

15* 



166 



STOKES'S THEORY AND PRACTICE. 



kind found in the secretion of the pancreas, which is considered to 
bear a strong analogy to that of the salivary glands. Besides, in 
the case mentioned by Mr. Lloyd, where the duct of the pancreas 
was obstructed by calculous secretions, this fatty matter has been 
discharged ; and hence we cannot, I think, refer it to the pancreas. 
Whence, then, does it come 1 Is it a secretion from the surface of 
the intestines ? This is a question which it is hard to determine. 
We do not yet know, nor have we ever met with that state in 
which lesion of structure in the mucous membrane of the intestinal 
canal has been followed by a discharge of fatty matter. We have 
discharges of serum, lymph, blood, and pus, from the surface of the 
intestines, according to the nature of the disease ; but we know of 
no pathological condition as the result of which fatty matter may 
be produced. Again ; cases of every known form of disease in the 
liver, pancreas, and intestinal canals, occur without this discharge 
at all. In the present state of medicine, the probability is that this 
discharge is the result of a sort of metastasis of the secretion of fat 
from the other parts of the body in which it is usually deposited, to 
the surface of the digestive tube, where it is poured out somewhat 
in the same way as in cholera ; the fluids of the body are rapidly 
absorbed and eliminated by the intestinal canal. This supposition, 
without attempting to bring it forward as the true solution, fur- 
nishes us with the best explanation of the case. In the case of the 
patient who discharged this substance by stool and with the urine, 
the emaciation came on rapidly, as if all the fat of the body had 
been absorbed and carried out of the system ; here, too, the fat was 
discharged from another mucous surface. In the other remarkable 
case, where a vast quantity of this substance was thrown up by 
vomiting, the emaciation was so great that the patient's skin hung 
in loose folds about him. When we reflect, too, that there is no 
recognised disease of the intestines, liver, or pancreas, to which this 
discharge can be referred, we cannot help believing that it is the 
result of a metastasis in the secretion of fat. 

The next point in this matter which we have to consider is, what 
is the best mode of treatment ? This question, I believe, cannot be 
answered at present ; nor can our practice be anything but empi- 
rical until we have more light throw upon the subject. With a 
view to increasing our knowledge, I beg of you to make this disease 
the subject of your practical investigations, and to have a look out 
for this discharge, because I believe it often occurs unnoticed, from 
our neglecting to inspect the evacuations. 



LECTURE XV. 

Acute and chronic hepatitis — Pathological differences — Effect of climate — General and 
local symptoms — Character of fever — Pain of shoulder — Use of pleximeter — Com- 
plication with jaundice — Resolution — Abscess — Various openings of the latter — 
Cicatrisation. 

I propose to-day to draw your attention to the subject of inflam- 
mation of the liver. This is the disease which you meet with in 



ACUTE AND CHRONIC HEPATITIS. 



167 



books under the general name of hepatitis ; but it is of great im- 
portance to distinguish between acute and chronic hepatitis for 
this reason — acute hepatitis implies something specific, an organic 
change, the nature of which is well known and accurately defined ; 
but chronic hepatitis implies nothing of this certainty of the nature 
of organic change, inasmuch as there is no single one of the recog- 
nised disorganizations of the liver, which may not, and have not 
occurred, with chronic hepatitis as an existing cause, or a promi- 
nent symptom. When we speak of acute hepatic inflammation, 
we speak of a disease, of which the structural lesions are sufficiently 
understood ; but when we treat of chronic hepatitis, we treat of a 
disease in which there may be a great variety of organic changes. 
Chronic irritation of the liver may in one patient be followed by 
the development of hydatids; in another by cancer, or tubercle; in 
a third, by hypertrophy of one or both of its elementary tissues ; in 
a fourth, by atrophy ; and in a fifth, by abscess ; so that under the 
chronic form of hepatitis, we may have many different lesions com- 
prised. Under the acute form, we have only vascularity, soften- 
ing, yellow degeneration, and suppuration. These, which are the 
ordinary results of acute hepatic inflammation, are the same as the 
results of active inflammation of other parenchymatous organs. 

It is an interesting fact, and connected with the predisposition to 
acute diseases of the abdominal viscera in warm climates, that acute 
hepatitis is much more prevalent in those countries than it is here, 
and this is particularly true with respect to the East Indies. You 
recollect, in one of my lectures, I alluded to the greater suscepti- 
bility to disease, the extraordinary nervous excitability of the 
digestive mucous membrane in warm latitudes, and hence that a 
large proportion of the diseases of those climates was characterized 
by the predominance of inflammation in the stomach and intestines. 
The same thing occurs with respect to the organs which are con- 
nected with the digestive tube; and hence it is that diseases of the 
liver and spleen are so frequently met with between the tropics. 
A very remarkable fact, bearing on this point, has been mentioned 
to me by Staff-Surgeon Blest. He states that, in the East Indies, 
hepatic disease in animals is no unusual occurrence ; that animals 
brought to, India from more temperate climates are peculiarly 
subject to it ; and that in them it is a common cause of death. 
He has seen many cases of hepatic abscess in dromedaries and 
horses, under these circumstances; a fact of great interest, when 
considered with the liability to tubercle in animals brought from 
rearm climates to these countries. In these countries, acute 
hepatitis in its highest degree is a rare disease ; in fact, so rare, 
that it is only in our own time that anything like a series of cases, 
by which you would compare the disease in these countries with a 
similar affection in others, have been published. A series of cases 
by Louis, and another by Dr. Graves and myself, published some 
time since, are all that we have on the subject. It is somewhat 
extraordinary that a sort of epidemic tendency to acute hepatic 



168 



STOKES'S THEORY AND PRACTICE. 



inflammation, and the formation of abscess, occurred in the coun- 
tries about the middle of the year 1828. Up to this peridd, abscess 
of the liver was looked upon as a very rare disease in Ireland ; a 
case of it was met with in hospital once perhaps in twelve months 
or two years ; but at the period to which I allude, almost every 
great hospital in Dublin had several cases ; and in the Meath alone 
we had a great number, out of which seven or eight proved fatal. 

We have now to consider this acute inflammation of the liver ; 
and first, with respect to the symptoms. Were I lecturing on 
pathology merely, I would commence with the organic changes ; 
but as I have chiefly kept in view, during my present course, the 
practice of medicine, I shall begin by detailing the symptoms. 
You will get a good idea of the symptoms of acute hepatic inflam- 
mation by dividing them into local and general ; by doing this, you 
will simplify the matter, and acquire accurate and defined notions 
of the disease. Now, the local symptoms are, pain in the region 
of the liver, tenderness ever the affected organ, and a degree of 
tumefaction perceptible to the touch ; pain, tenderness, swelling — 
here are the local symptoms. What are the general? Inflamma- 
tory fever, and lesion of the digestive function ; and in addition to 
this, if the case be severe, you have functional derangement of the 
respiratory and cerebral systems. You have, then, in a case of 
acute hepatitis, the general symptoms of inflammatory fever, with 
lesion of the digestive function ; and if the case be severe, of the 
respiratory and even cerebral systems, the local symptoms being 
pain, tenderness, and tumefaction. 

Now, with respect to the character of the fever which accom- 
panies this disease, it is in all cases nearly the same; and here we 
come to an interesting and curious fact. You recollect that, in 
speaking of gastro-enteric inflammation, I alluded to the nature of 
the accompanying fever, and stated that it was (commonly) of a 
low character, and that there was no local inflammations in which 
the fever was so often typhoid as in the affections of the gastro- 
intestinal surface. This, I believe, has been one great cause of the 
ignorance of medical practitioners with respect to gastric and 
enteric inflammations ; they have been most commonly looked upon 
as cases of typhus, and treated accordingly. In acute hepatitis, \ 
however, we do not observe this typhoid prostration. Though 
closely connected with the gastro-intestinal system, the liver does \] 
not, in its acute inflammatory state, produce the same manifest ) 
depression of the vital powers. On the contrary, we have, in the 
early period of the disease in this country, high inflammatory f 
fever, hot skin, and full bounding pulse ; a state in which few 
would be afraid to employ the lancet with boldness. Patients 
labouring under acute inflammation of the liver, generally have 
high sympathetic fever, a full, strong, and accelerated pulse, with 
the local symptoms above described; and, in addition to these, we 
frequently observe bilious vomiting, considerable thirst, derange- 
ment of the bowels, and scanty high-coloured urine. The tume- 



ACUTE AND CHRONIC HEPATITIS. 



169 



faction is more or less evident, and when this is accompanied by 
severe pain, there is considerable difficulty of breathing, a circum- 
stance which sometimes occasions this disease to be mistaken for 
pleurisy. There are two remarks to be made on this subject. In 
the first place, it sometimes happens that acute inflammation of 
the liver and of the lower part of the lung occur at the same time, 
particularly where inflammation attacks the diaphragmatic surface 
of the liver. Here you frequently have an extension of the inflam- 
matory process to the corresponding surface of the pleura, or the 
two diseases co-exist from the first. Under such -circumstances, 
disputes, as to which organ is engaged, are often unnecessary. 
Again, in the early period, and when the attack is acute, the 
diagnosis of inflammation of the diaphragmatic surfaces of the liver, 
or pleura, is comparatively of little consequence, as both, demand 
the use of calomel and opium, leeches and the lancet; and, in the 
early stages at least, both are amenable to the same treatment. But 
it is not so in the chronic stage of either. Here the diagnosis is of 
great importance ; and when I come to treat of pieuritis, I shall 
draw your attention to some researches of mine on this subject, 
which I hope have set this question at rest. 

The pain which accompanies acute hepatitis varies much in 
situation. Sometimes it is felt in the shoulder, sometimes under 
the short ribs, sometimes in the loins, and frequently in the 
epigastrium. You have all heard of pain at the top of the shoulder 
as a common symptom of liver disease ; in fact, so common as to be 
looked upon by some as a pathognomonic symptom. I believe that 
a great deal too much stress has been laid on this circumstance. It 
is now discovered, that so far from being a constant, or even a 
common symptom, it is one which is of exceedingly rare occur- 
rence. I have never seen a case of acute hepatitis with pain in the 
shoulder; I have sometimes observed it in chronic, but never, to 
my recollection, in acute cases. Andral states that it is very seldom 
met with; Dr. Mackintosh says the same, and, if I recollect aright, 
looks upon it as a symptom not worth inquiring about. Now, I 
have seen some medical men who considered this pain in the 
shoulder as a diagnostic of such value, that if it happened to be 
absent they concluded there was no hepatic disease. The fact is, 
that it is anything but constant. You may have it in some cases, 
particularly of chronic hepatitis, and not in others ; besides, it fre- 
quently depend upon other causes— for instance, upon pneumonia 
of the top of the right lung, or it may be caused by incipient 
phthisis, aneurism of the arteria innominata, or righ subclavian 
artery, and other diseases. It is of very little consequence whether 
it be absent or present; and the only reason why I dwell upon it is, 
to show you its real value as a^symptom. 

There is one remarkable circumstance connected with the pain 
of an acute hepatitis. In one case, you will find that the pain is 
very acute and constant, in another, that little or none is felt ; and 
when you come to investigate the cause of this after death, it gene- 



170 STOKES'S THEORY AND PRACTICE. 

rally happens that, in cases where the pain was violent, the inflam- 
mation existed on the surface of the liver, and in those where little 
suffering was experienced, deep in the substance of that organ. 
This is a curious fact ; but it may be looked upon as an illustration 
of a general law, that if we consider inflammatory affections of the 
solid viscera, ice shall find that the more superficial the inflam- 
mation the more painful it is; and, on the other hand, the more 
deep-seated it is the more is it latent, so far as pain is concerned. 
Thus : if you take a case of inflammation of the substance or cen- 
tral parts of the brain, you will find that the disease is to be recog- 
nised often not by pain, but by the lesions of the sentient and 
locomotive powers; whereas, in inflammations of the membranes, 
on the surface of the same organ, one of the most prominent symp- 
toms is agonizing headache. In the next place, go to the lung ; 
take a case of deep-seated pneumonia, and contrast its almost pain- 
less character with the lancinating torture of an acute pleuro- 
pneumony. In pneumonia the pain is dull, and scarcely complained 
of; but pleuritis unaccompanied by acute suffering is extremely 
rare; in fact, where you have the signs of inflammation of the 
parenchymatous tissue of the lung, with sharp pains in the chest, 
you may very safely make the diagnosis of pleuro-pneumony. The 
same absence of pain is by no means unusual in inflammatory affec- 
tions of the mucous membrane of the intestines ; but if the inflam- 
mation should chance to extend to its peritoneal investment, you 
will have this state rapidly exchanged for one of intense suffering. 
So it is with respect to the liver ; disease on the surface of that 
organ is attended with severe pain ; but enormous destruction of its 
deep-seated parts may take place, and your patient complain merely 
of a sense of uneasiness. 

A late author on hepatic affections, Dr. Bell, who has written a 
treatise on the diseases of India, describes two forms of acute hepatic \ 
inflammation, which are different as to their seat and character. In 
one of these, which he terms sero-hepatitis, the disease is on the | 
surface of the liver ; in the other, which he terms puro-hepatitis, 
it exists in the centre. In the sero-hepatitis, he states that the 
patient is attacked with sudden pain in the region of the liver, and 
this is so severe that even the weight of the bed-clothes is insupport- 
able ; the patient cannot bear to turn or lie on his left side, from the s 
pressure exerted in that position on the inflamed organ. But the 
deep-seated, or puro-hepatitis, may go on in such a latent manner, 
that the first symptoms you have of the existence of liver disease 
are those which mark the occurrence of suppuration. Neither the : 
patient nor his medical attendant will have reason to suspect 
inflammation of the liver, until the constitution and local symp- 
toms of the suppurative process direct attention to that organ, i 
Such are the statements of Dr. Bell, which I believe to be cor- 
rect, as they are supported by the concurrent testimony of many 
persons who have practised in India, with whom I have conversed 
on this subject. Mr. Annesly makes the same assertion ; and such 



I 



ACUTE AND CHRONIC HEPATITIS. 171 

was our experience in the succession of cases of hepatic abscess 
I which were under treatment in the Meath Hospital during the 
I year 1828. 

The next symptom which we have to consider, is the tumefaction 
I of the liver, and this is one of considerable importance. In order, 
1 however, to estimate the extent of this tumefaction with any degree 
| of accuracy, you must take one preliminary step, and that is, to 
j have the bowels fully evacuated. If the intestines are filled with 
i feculent matter or gas, you cannot do this in a proper manner. A 
j few hours before you make your examination, give the patient a 
full purgative draught, assisted, if necessary, by a strong purgative 
j enema. In this way, you empty the belly of collections of fequlent 
matter and aeriform fluid, and then you can with certainty and 
j satisfaction ascertain the extent of the swelling. You will then b(3 
i able (when your patient is laid in bed), perhaps, to see at once the 
: extent of the tumefaction, particularly where the parietes are not 
\ thick or loaded with fat; at all events, you will be able to feel it 
; with your hand, and in every case you can ascertain it by mediate 
l percussion with the pleximeter. I do not know any more important 
adjuvant, in making out the diagnosis of an enlarged liver, than the 
use of mediate percussion. For instance, suppose you have a patient 
labouring under acute hepatitis, and that the tenderness of the organ 
is so great that he cannot allow you to make the requisite degree of 
pressure to ascertain the extent of the swelling ; take the top of 
j your stethoscope, apply it over the region of the liver, make use of 
j light percussion, and you will find, with the greatest accuracy, how 
I far the tumefaction of the liver extends, by the dulness of sound 
heard over the inflamed organ, and exactly limited to it. In this 
way, you can make a most satisfactory examination, without giving 
your patient any pain ; and this is a matter of some importance, as 
you will meet with many cases in which there is exquisite tender- 
ness, and where the patient will not bear the slightest pressure. I 
would advise you, therefore, to practise this mode ; it gives little or 
no pain, it is exceedingly simple, and I have not the slightest doubt 
of its accuracy. Now, the value of this tumefaction, as a sign of 
the existence of hepatic inflammation, depends very much on the 
recent nature of the attack. If a man, who was in perfect health 
a few days back, complains of pain in his right side, and has a 
i tumour in that situation, it is to be presumed that this tumour does 
not depend upon the presence of a collection of fluid in the pleura, 
and, consequently, that the tumefaction is not produced by an 
empyema. Then, if, in connection with fever, and pain in the right 
side, you can ascertain the existence of a tumour in the region of 
the liver, and that it has occurred within a short space of time, you 
I may be pretty sure that it is not an empyema, but an inflamed and 
j enlarged liver. 

Jaundice has also been considered as a symptom of hepatic in- 
I flammation, but it is one which is by no means constant. Again, 
| you may have most extensive hepatitis, with slight jaundice, and 



172 STOKES'S THEORY AND PRACTICE. 



universal and intense jaundice, with trifling or no hepatitis; and, 
what is equally singular, you may have very little perceptible dis- 
ease of the liver with scanty secretion of bile; and, on the other 
hand, the liver may be burrowed with abscesses, and at the same 
time you find bilious stools, and after death the gall-bladder may 
be found filled with pure healthy bile. I thought, at one time, that 
I could explain the presence or absence of jaundice in cases of 
hepatitis, by supposing that, where it occurred, the jaundice was the 
resYilt of inflammation of the gastro-duodenal mucous membrane ; 
and to prove this, I drew up a table of cases, of which one half 
were complicated with jaundice, and the other not. I found, how- 
ever, that in a great number of cases, where the tube was free from 
disease, the hepatitis was complicated with jaundice ; and in a 
similar number of cases, where the same circumstances were ob- 
served, the tube was in a state of disease. So that we may have, 
as you perceive, hepatitis and jaundice, with and without disease of 
the intestinal tube ; and whether we look to the cases of hepatic 
inflammation, unaccompanied or complicated with jaundice, the state 
of the gastro-intestinal mucous membrane throws, as yet, no light 
on the subject. It appears, then, that the occurrence or non-occur- 
rence of gastro-duodenitis does not explain why it is, that in one 
case of hepatic inflammation jaundice is a prominent symptom, and 
in another is completely absent. 

In some cases of acute inflammation of the liver, the natural 
secretion of that organ seems to be totally annihilated. A curious 
case of this kind occurred under the care of Dr. Graves, in the 
Meath Hospital, where the slightest trace of bile did not exist in 
the gall-bladder, which was filled with a transparent mucus. In I 
some instances you will find plenty of bile discharged, in others 
none ; in some patients the stools are observed to be clay-coloured, 
or very faintly tinged with bile : in others they are healthy, and 
natural in colour, as well as consistence. From our own expe- i 
rience, and from studying the series of cases* published by j 
Louis, we have come to the conclusion, that neither the presence 
nor the absence of bile in the stools affords any positive or useful 
information as to the different stages of this disease, its progress or 
termination. 

Acute hepatitis terminates in a variety of modes. It may termi- 
nate by resolution — here the organ returns to its former healthy (I 
state, without any appreciable change of structure or function ; it I 
may terminate by the formation of matter — here we have suppura- 
tion and abscess ; it may terminate in gangrene ; and, lastly, it may, 
without the occurrence of suppuration or gangrene, pass into 
chronic hepatitis, of which the result may be a variety of morbid 
changes in the organ itself. When the patient is so fortunate as to 
meet with the first of these terminations, the fever, pain, and tume- 
faction, gradually disappear. On making an examination with the 
pleximeter, you will find that part of the belly which was rendered 
dull by the tumefied liver becomes clear on percussion ; you will ■„ 

i 



ACUTE AND CHRONIC HEPATITIS. 



173 



find, also, that the dulness of the lower part of the chest, on the 
j right side, is removed, the patient can breathe without any difficulty, 
I and lies on the affected side without inconvenience. But when the 
j disease passes into the suppurative stage, the train of phenomena 
I exhibits a marked difference. What we generally observe under 
I such circumstances in this country is, that there is a change in the 
I constitutional symptoms ; the fever, which has been hitherto inflam- 
| matory, now becomes hectic. The pulse continues quick, but is 
: diminished in strength and volume ; the countenance becomes pale 
j and collapsed, the patient feels languid, restless, and disposed to 
| sweat, and his perspiration has a sour smell. He may also have a 
! miliary eruption, and this continues for some time, with an increase 
or persistence in the size of the hepatic tumour. When these 
i symptoms appear, there is every probability that matter is forming, 
s or has been already formed. The patient then begins to complain 
of increased weight in the region of the liver, and in some cases 
the integuments over that organ are swollen, and slightly dis- 
coloured. I have observed that, in some instances, the pain con- 
centrated itself in one point, and in this situation it was afterwards 
found that abscess had formed. These are the ordinary symptoms 
which usher in, or accompany, the suppurative stage of hepatic 
j inflammation ; but there are also cases, even in this climate, where 
I this marked change of symptoms is not seen, and where abscess 
j forms rapidly, and with symptoms which might be supposed to 
I belong to the early period of the disease. This, however, is par- 
ticularly true with respect to hepatic abscess in the East Indies. 

I believe I mentioned in a former lecture a very curious fact, 
namely, that it has been often found impossible to salivate persons 
labouring under hepatic abscess, so that the presence of matter or 
not, in the liver, may be determined by the circumstance of the 
patient being susceptible or not of the full effect of mercury. The 
liver, in this case, seems to illustrate that pathological law which I 
alluded to in spfeaking of dysentery ; that the more intense an 
inflammation, the greater is the difficulty of producing ptyalism. 
My friend, Staff-Surgeon Marshall, and also Mr. Annesly, agree in 
stating, that it is exceedingly rare to find a case of hepatic abscess 
in which the salivary glands have been affected by mercury, and 
our experience of the disease in this country exactly coincides with 
their opinion. It has been also observed, that hepatic abscess may 
form in an insidious and latent manner, when it happens to be com- 
plicated with disease of other organs. This affords us an illustra- 
tion of a law already laid down, that the more complicated an 
j affection is, the more obscure is its character. Again, we may, as 
the result of acute hepatitis, have one or two vast cavities formed 
! in the substance of the liver, or we may have a number of very 
| small abscesses. I recollect a case which occurred some time ago 
near this city; the patient exhibited the symptoms, and was, in fact, 
supposed to labour under intermittent fever. After some time, death 
took place, and, on dissection, a number of small abscesses were 

16 

1 

I I c • 
I 



174 



STOKES'S THEORY AND PRACTICE. 



found in the liver, of which, during life, there was no symptom, 
except that which I have just mentioned. 

When an hepatic abscess attains a certain magnitude, it has a 
tendency to burst and discharge its contents. If it escapes exter- 
nally, it makes its w r ay in a great variety of directions, sometimes 
in the epigastric, sometimes in the hypochondriac, sometimes in the 
lumbar region, and there are cases on record, in which the matter 
has burst in the right axilla, by a sinuous passage beneath the integu- 
ments of the chest. When it bursts internally, it sometimes perfo- 
rates the diaphragm, and gets into the cavity of the pleura, or, what 
is more commonly the case, into the substance of the lung. The 
matter of an hepatic abscess very rarely gets into the pleural sac, 
and hence we very seldom have an empyema as the result of this 
occurrence, because the pleura being extremely liable to adhesion 
as a consequence of the inflammatory process, and the passage of 
matter being always preceded by inflammation, the opposed sur- 
faces of the pleura become glued together by coagulable lymph, 
which prevents the hepatic pus from getting into the pleura, at the 
same time that it favours its passage into the lung. The opening 
into the lung is one of ordinary occurrence ; many cases of it are 
on record ; and serious as the lesion may appear, it is, perhaps, one 
of the best modes in which hepatic abscess may terminate by inter- 
nal opening. Many persons have recovered after such a termina- 
tion ; and I have seen myself three cases in which it was certain, 
and a fourth in which it was probable, that the matter had been 
expectorated by the mouth, with a favourable issue. We are, then, 
as far as the records of medicine and our experience in the Meath 
Hospital go, warranted in looking on this termination as a favour- 
able one. Hepatic abscess may also open into the pericardium ; but 
this is very rare, there being only one case of this kind, which is 
given by an American author. It may open into various parts of 
the intestinal canal, the stomach, duodenum, and colon ; it may also 
discharge its contents into the right kidney, into the vena cava, or 
into the peritoneum, and thus cause violent peritonitis and death. 

The diagnosis of these different openings of an hepatic abscess is 
easy, and founded on the same principle, the occurrence of new and 
extraordinary symptoms, connected with the adjacent viscera, which 
were not before diseased — symptoms of a sudden discharge of pus 
from, or into, these organs. Suppose you have a case of hepatic 
abscess, and that, during the progress of the disease, the patient has 
sudden and enormous expectoration of purulent matter, without 
any preceding signs of inflammation of the lung, it is probable that 
the abscess has opened into the lung ; or suppose that, during an 
attack of acute hepatic disease, your patient is all at once seized 
with nausea, and vomits a quantity of purulent matter, and, imme- 
diately after this, you perceive that the tumefaction of the liver sub- 
sides. Here the matter has been discharged into the stomach ; in 
other cases you have it discharged into the duodenum or colon. 
Again, you may have instances where the matter gets into the peri- 



HEPATIC ABSCESS. 



175 



toneum ; here you may observe the occurrence of rapid peritonitis 
So that, in all cases of this kind, the diagnosis is founded on the 
same principle, the occurrence of discharge of pus from, or into, 
organs which previously had been considered to be in a healthy 
state, and this coinciding with a subsidence of the original 
j tumour. 

In persons who, under such circumstances, recover, it is natural 
> to expect that cicatrisations should exist in the liver. Louis states 
i that he has never seen this ; with respect to our cases of hepatitis, 
j we can only say that the fatality of the disease has afforded us no 
opportunity of investigating this point of morbid anatomy. Mr. 
Annesly, however, in his work on the diseases of India, has given 
drawings exhibiting this appearance. 1 recollect one case of a 
man in the Meath Hospital, who had been a soldier in the East 
; India Company's service, and had been treated for liver disease ; 
this man died of phthisis, and, on dissection, the surface of the right 
lobe of the liver was found puckered, forming a hollow with a car- 
| tilaginous basis, strongly resembling what we might suppose to be 
! the cicatrix of an abscess. 



LECTURE XVI. 

Diagnosis of the rupture of hepatic abscess — Pulmonary openings — Case of double 
opening — Puncture of the gall-bladder — Gangrene of the liver — Its connection with 
hepatic apoplexy — Diagnosis of distended gall-bladder — Its causes — Inflammation of 
the parietes over the liver — Sympathy of the integuments. 

I broke off at my last lecture while engaged in considering the 
phenomena of hepatic abscess, and you will recollect I spoke of the 
various modes in which these abscesses may open internally, and 
stated that the diagnosis in all cases was founded on the same prin- 
ciple, which is this — that during the prevalence of symptoms indi- 
cating the existence of suppuration of the liver, some new organ 
becomes suddenly affected, the nature of the affection being what 
would be produced by the sudden rupture of an hepatic abscess 
and a discharge of pus into some of the neighbouring viscera, and 
this coinciding with the disappearance, more or less, of the original 
tumour. Now, when we consider the various internal openings of 
an hepatic abscess, we find that they admit of being divided into 
j two classes, first, those in which the matter is effused into cavities 
! having a communication with the exterior of the body, as the lung, 
: digestive tube, and kidney. Here, in addition to the symptoms 
' already alluded to, we have a sudden discharge of pus from the 
| stomach or bowels, from the lungs, or by the urinary passages. 
! But we may also have the matter discharged into shut cavities 
| having no external communication, as where the contents of the 
I abscess open into the peritoneum, pleura, or pericardium. You 
j will readily perceive that of these two classes of openings, those in 



176 



STOKES'S THEORY AND PRACTICE. 



which the matter escapes into cavities having no communication 
with the exterior are the most unfavourable. The confined pus 
excites violent and generally fatal inflammation, and we have a 
dangerous empyema, a rapid peritoneal inflammation, or intense 
pericarditis. 

I stated, that of the internal openings of an hepatic abscess, one 
of the most favourable is that in which the matter is discharged into 
the right lung, and I described briefly the mechanism of this curious 
process. We are warranted, I think, in declaring this to be a 
fortunate termination, because there are many instances on record 
of persons having recovered under such circumstances. A very 
near relative of mine presented an example of this. He was at- 
tacked with symptoms of acute hepatitis, for which he was attended 
by some of the most eminent physicians in Dublin. His treatment 
was bold and vigorous; he had free bleeding, both general and 
local, mercury, and every other means calculated to remove in- 
flammation, but all proved ineffectual. His pulse became rapid ; 
he began to sweat ; the hepatic tumour increased in size, and pre- 
sented a distinct sense of fluctuation ; there could be no doubt of 
the existence of suppuration in the substance of the liver. One 
morning he was suddenly seized with a violent fit of coughing, and 
during the course of the day expectorated more than a large tea- 
cupful of pus; towards evening this increased, and on examination 
it was found that the tumour was remarkably diminished. The 
expectoration continued during the whole night, and in the morning 
it was observed that there was scarcely any appearance of the 
hepatic swelling. It was singular, and tends to confirm the idea 
that the matter had been discharged into the lung, that in the erect 
position this gentleman had scarcely any expectoration, but in the 
horizontal it was always extremely copious ; a circumstance which 
you can easily understand by considering, that in the recumbent 
posture the purulent matter would find a more easy passage into 
the lung. In this case, it would appear that the communication be* 
tween the liver and lung was very free, for I remember that on 
one occasion by making pressure over the liver, he said I w r as 
forcing the matter into his chest, and the pressure was followed by 
an instantaneous and copious expectoration. This frequently oc- 
curred. A medical friend of mine residing in Dublin, mentioned to 
me some time since the case of a large robust drayman, addicted 
to whiskey drinking, whom he attended for an attack of acute 
hepatitis. At a time when the liver was very much increased in 
size, and well-marked symptoms of suppuration present, he ob- 
served that sudden expectoration of pus took place, which conti- 
nued for several days, with manifest subsidence of the hepatic 
tumour and complete recovery. Three cases of this kind came 
under my notice in the Meath Hospital. One of the patients had 
symptoms such as I have before described as exhibiting a striking 
similarity to yellow fever, from which he recovered, and was dis- 
charged, with no other remarkable symptom but quick pulse. 



i 



i 



HEPATIC ABSCESS. 



177 



Shortly afterwards he returned, complaining of pain in the right 
hypochondrium, with rapid pulse, profuse night sweats, and a slight 
I cough. At first his appearance struck me as being characteristic 
! of phthisis, and under this impression I repeatedly examined the 
I chest by the stethoscope and percussion, but could not detect any 
lesion. The man had only a slight cough, and this was totally 
! insufficient to account for his symptoms. The nature of the case 
| was soon manifest : one morning the patient stated that he felt as 
i if something had given way in his chest during the night, and he 
| was from that time expectorating large quantities of purulent 
! matter. On examining the lower portion of the left side, I found 
|j that it sounded completely dull on percussion, and that the physical 
\ signs of an accumulation of fluid in the bronchial tubes were 
] extremely distinct. That this dulness w T as the result of the effusion 
in question is proved by the previously healthy state of the lung. 
! The very day before 1 had carefully examined this part of the 
chest, and found it quite healthy. There was not the slightest 
j resonance of voice in this portion after the accident, because the 
1 tubes were so completely filled ; so that in this case the return to 
health was accompanied by increase of bronchophonia, a fact that 
sets the question of the nature of the accident at rest. It may ap- 
pear strange that in this case the puriform matter entered the left 
lung instead of the right ; but this is sometimes the case, particu- 
larly when the abscess forms in the left lobe of the liver. 

I shall now draw your attention to the particulars of a case which 
I I look upon as almost unique, and which derives additional interest 
from the accuracy of the> diagnosis. It is of great importance that 
you should have clear ideas on the subject of hepatic abscess, for, 
though the disease is not of common occurrence in this country, 
still, if called on to pronounce an opinion on a case of this kind, 
the least difference in the- quantity of your information may be of 
consequence. The patient, who was the subject of this disease, 
was admitted into the wards of the Meath Hospital in August* 1828. 
The history of his case was* that he had been labouring, sometime 
previously, under obscure symptoms of an hepatic affection, accom- 
panied by slight fever and jaundice, which had gradually subsided. 
Three weeks before admission he stated that he had irregular fits of 
shivering, followed by sweating, and when he came to the hospi- 
tal he complained of sickness of stomach, but particularly of cough, 
and difficulty of breathing, which were extremely harassing, and 
said that he came in chiefly to be cured of his cough. He was 
[ considerably emaciated, and looked pale and low, but his stools had 
| a natural appearance. On considering the history of his case and 
| the symptoms then present, it struck me that it was either hepatitis 
I with suppuration, or empyema of the right side with irritation of 
the liver. At that time I had not made my researches on the diag- 
nosis of empyema, and I must confess that I experienced a great 
deal of difficulty in determining the nature of the case. I found 
the right side considerably dilated, with dulness on percussion 

10* 



\ 



178 STOKES'S THEORY AND PRACTICE. 

over its inferior half, but the intercostal spaces were not distended, 
and preserved their natural appearance. The case went on this 
way for some time. Permit me to draw your attention for a mo- 
ment to this point. Dilatation of the right side may result from the 
pressure exercised upon it by a solid or by a fluid mass. If the 
mass be solid it will push the ribs outwards, but the intercostal 
spaces will still preserve their natural appearance. But if the 
protrusion of the side be the result of pressure by a fluid mass, the 
intercostal spaces will be acted on even more than the ribs, and the 
sulci, which mark their situation, will be effaced. Now, in this 
case the intercostal spaces were evident, and from this circumstance 
I determined that it was a liver disease. The patient continued 
for a fortnight without exhibiting signs of any material change, and 
then the tumour increased very much in size, but there was no ap- 
pearance of pointing. At this time the patient was visited and 
examined by a number of medical men, and all agreed that it was 
a case of deep-seated suppuration of the liver. Under these cir- 
cumstances it was thought advisable to make an incision through 
the integuments down to the peritoneum, as recommended by Dr. 
Graves, and to keep the wound open by filling it with lint. This 
operation was performed, and the wound kept open for several 
days, but no matter came. On the sixth day the patient began to 
sink, his face became hippocratic, his extremities cold, and every 
one thought he was dying. During the course of the day it was 
observed that there was a circumscribed tumour, w r ith a distinct 
sense of fluctuation, situated close to the wound, and towards the 
right side of the mesial line. Here is an important stage of the 
case ; — a man presenting evidence of suppuration in the liver has 
an operation performed on him to favour the exit of pus externally, 
and some time after this we find a circumscribed fluctuating tumour, 
nearly in the situation of the wound. We concluded that the he- 
patic abscess was pointing in that situation, and it was determined 
to pass a lancet cautiously into the tumour. This was done, but to 
our astonishment, instead of pus pure bile escaped through the 
incision. It was clear that w r e had mistaken a distended gall-bladder 
for an abscess, and this I need not tell you was a serious error. It 
is singular, however, that the accident was not followed by any 
bad consequences. About two hours after the operation the patient 
went to stool, and passed two large evacuations, consisting chiefly 
of a vast quantity of purulent matter. Next morning he was 
surprisingly well, and the hepatic tumour had considerably dimi- 
nished. His countenance recovered its natural expression, his 
spirits were quite elated, his pulse had become tranquil, and the 
liver was manifestly returning to its ordinary dimensions. He 
began to sit up, was put upon generous diet, could walk about the 
ward, and was talking of leaving ihe hospital. From the period, 
however, at which the discharge of pus took place he had an obsti- 
nate diarrhoea, and though he took a great deal of nourishment he 
was still pale and emaciated. Twenty-two days after the subsi- 
dence of the tumour, another swelling began to make its appearance 



HEPATIC ABSCESS. 



179 



in the epigastrium, which increased daily, and it was obvious that 
another abscess was forming in the left lobe. About a fortnight 
after this he was suddenly seized with excruciating pain in the epi- 
gastrium, followed by symptoms of peritonitis. The tumour in the 
epigastrium subsided, but the patient sank in a few days of the 
peritoneal inflammation. Let me recall the circumstances of this 
case. First, we have obscure signs of the existence of abscess, then 
the sudden escape of matter from the bowels, accompanied with 
subsidence of the hepatic tumour ; in the next place a persistence 
of diarrhoea and emaciation, and, lastly, we have a new tumour in 
the epigastric region, disappearing on the supervention of symptoms 
of acute peritonitis. From a consideration of all these circum- 
stances I stated to the class that I should expect to find evidences 
of the abscess in the right lobe, which w r as the first affection, and J 
ventured to say, that the opening between it and the intestinal tube 
was still pervious. I was led to form this opinion from observing 
the persistence of the diarrhoea, to check which all the ordinary 
remedial means had failed. This was the first part of the diagnosis. 
In the next place I stated my belief that the gall-bladder had been 
I punctured, but could not explain why the bile had not escaped into 
the peritoneum. Thirdly, I said that an abscess had formed in the 
i left lobe, which had discharged its contents into the peritoneal 
cavity. All this was stated publicly, and on consideration you will 
find that there was no great difficulty in making the diagnosis. On 
dissection, we found a cavity in the right lobe with a small quantity 
I of matter in it, and having a free communication with the duode- 
num. The fundus of the gall-bladder was found adhering to the 
parietal layer of the peritoneum, and the mark of a lancet wound 
in it was evident. A recent abscess was discovered in the substance 
of the left lobe of the liver, from which the matter had escaped into 
the peritoneum by a passage capable of admitting a small quill. 
Every part, therefore, of the diagnosis of this case was perfect, and 
borne out by the nccroscopic appearances. You will see the 
details of this very interesting case in a paper published by Dr. 
Graves and myself, in the fifth volume of the Dublin Hospital 
Reports. 

This case is exceedingly interesting, because it illustrates two 
remarkable terminations of hepatic abscess: in one instance, by 
opening into a cavity which had an external communication, in the 
other, into a shut sac. The patient recovered from the first abscess, 
; and would have done so effectually if the fistula had closed (no 
uncommon event) ; but he could scarcely have recovered from the 
second, because, where the matter escapes into the peritoneum or 
j pleura, the patient almost invariably dies of acute inflammation 
i of these cavities. This case derives additional interest from the 
! circumstance of the gall-bladder having been opened. I believe this 
| -is the only case on record in which an opening made into the gall- 
bladder has not been followed by fatal consequences. I might 
detail many other cases of hepatic abscess, but I must at present 



180 STOKES'S THEORY AND PRACTICE. 

refer you to the paper already alluded to, in which we have pub- 
lished the results of our experience on the subject. 

Some authors have mentioned gangrene, or mortification of the 
liver, as one of the modes in which acute hepatic inflammation 
may terminate. It is now however agreed, that this is one of the 
rarest terminations we can meet with ; in fact, that there is hardly 
any organic disease which so seldom occurs. Mr. Annesly states, 
that in all his dissections (and these were very numerous) he never 
met with a case of gangrene of the liver. Andral, who has exa- 
mined some thousands of bodies, has only met with a single case : 
this, with another which was under the care of Dr. Graves, and 
appears to have been a genuine example of mortification of the 
liver, are almost the only cases of which I have any distinct recol- 
lection. - The case under Dr. Graves was that of a patient in Sir 
Patrick Dun's Hospital, who laboured under chronic inflammation 
of the liver, with ascites, jaundice, swelling of the lower extremi- 
ties, and an incapability of lying on the left side. After this man 
had been about eleven days in the hospital he began to complain of 
tenderness and pain of the belly ; he was next seized with vomiting, 
and threw up a large quantity of fetid matter. Soon after this he 
sank; and, on dissection, numerous marks of chronic disease were 
found in various parts of the substance of the liver ; but in the 
left lobe there was a cavity which was distinctly gangrenous, and 
had in the centre of it a large mass of slough. I think that there 
can be no doubt that in this case the disease was actual gangrene t 
of the liver. I think, too, it may be very fairly doubted whether 
gangrene of the liver is the result of inflammation, properly so j 
called, in any case ; and I believe it would be a very interesting 
subject for inquiry, to consider how far this disease may be the 
result of hepatic apoplexy, or effusion of blood into the substance 
of the liver. This is an accident to which the liver, as well as 
every other parenchymatous organ, is subject; and though efFu- ) 
sions of blood into its substance are by no means so common as 
similar occurrences in the brain and lungs, still it does not enjoy j 
anything like immunity from such lesions. We have good reason 
to believe, that in many cases blood effused into the substance of 
parenchymatous organs may, under certain circumstances, either 
undergo putrefactive decomposition and form a gangrenous abscess, 
or that, although no longer circulating in its vessels and effused , 
into the parenchyma of an organ, it may still retain its vitality to a 
certain extent, and, being modified by the powers of life, may give 
rise to the formation of various morbid products. In this way it is » 
thought that various tumours — cancerous, steatomatous, melanotic, 
and encephaloid — may originate. I am inclined to think that this 
sometimes occurs in the brain and lungs, and it is probable that it 
may happen in the case of the liver also. Further researches, 
however, are necessary, with respect to the elucidation of this mat- 
ter, before our opinions on it can possess a higher character than 
that of verisimilitude. 



I 



HEPATIC ABSCESS. 181 

While on the subject of hepatic abscess, it will be necessary to 
\ allude to one of its occasional complications — distended gall-bladder 
| — because this may be mistaken for the pointing of an abscess, and 
an operation be performed, and that this has happened more than 
I once is a positive fact. A distended gall-bladder has been mistaken 
j for the tumour formed by the pointing of an hepatic abscess, an 
opening has been made into it under this supposition, bile has escaped 
! instead of pus, and this getting into the cavity of the peritoneum, 
1 has given rise to rapid and fatal peritonitis. A remarkable case of 
| this kind has been detailed with great candour by the late Mr. 
• Todd, in one of the early numbers of the Dublin Hospital Reports. 
He was called suddenly to visit a girl, whom on his arrival he found 
to be in a dying state, labouring under great distension of the belly, 
almost insensible, moaning constantly with her jaw fixed, and pre- 
senting a distinct tumour in the hypochondriac region, which, from 
the history of her case, he was led to consider as an hepatic abscess 
pointing externally. He divided the integuments and muscles 
I down to the peritoneum, and having introduced a trochar, drew off 
' nearly three pints of bile, with apparent relief. Shortly afterwards 
1 violent peritonitis came on and the patient sank rapidly. After 
death the liver was found to be healthy, and the tumour to have 
been formed by a distended gall-bladder of enormous size. From 
this, after the operation, the bile had escaped into the peritoneum, 
causing intense and universal peritonitis. In making a diagnosis 
in such a case as this, everything will depend upon your knowledge 
' of the history and previous symptoms. The circumstances which 
produce distension of the gall-bladder, you will find upon examination 
do not bear any distinct resemblance to those which precede or 
accompany inflammation of the substance of the liver. We may 
have it from the obstruction caused by biliary calculi, and here you 
can make a tolerably sure diagnosis. We may have it from dis- 
ease of the duodenum, or of the head of the pancreas, or from 
the pressure of aneurismal tumours in the vicinity. Abscess of the 
liver is generally accompanied by symptoms of inflammation of that 
organ, but distension of the gall-bladder does not present any cor- 
responding train of phenomena. There may be some exceptions 
to this rule, but in making the diagnosis We must strike a balance 
of probabilities. The first part of our diagnosis then is this — the 
occurrence of a tumour in the hypochondriac region, not preceded 
or accompanied by any of the symptoms which characterize hepatic 
i inflammation. Another important diagnostic, and which I think 
I will apply in several cases, is this. In a case where abscess was 
' formed in the liver, the fluctuation, which is a sign of the existence 
! of fluid, is often preceded by a condition of the part in which there 
; is no sign of the presence of fluid; we have first induration and 
j swelling, and then the signs of fluctuation ; but this is not the order 
I of succession in the phenomena which characterize distension of the 
I gall-bladder. In abscess we have a hard tumour which gradually 
I softens; in case of distended gall-bladder we have the tumour soft 



i 



182 



STOKES'S THEORY AND PRACTICE. 



and fluctuating from the commencement. If, then, we have a tumour 
in the hypochondriac region, not preceded or accompanied by 
symptoms of hepatic inflammation, accompanied by jaundice, with 
a sense of fluctuation from the beginning, and unattended by hectic, 
the chances are indeed very great that it is not an hepatic abscess, 
but a distended gall-bladder. 

You will perhaps be surprised, that, in treating of the diagnosis 
of distended gall-bladder, I do not lay any particular stress upon 
position. The reason of this is, that the situations in which a dis- 
tended gall-bladder may be felt are extremely various. First, we 
may have it appearing in different parts of the hypochondrium, 
under the cartilages of the ribs. In the next place, we may have it 
between the cartilages of the ribs and the spine of the ileum. It has 
been observed by Andral in the iliac fossa, and he has seen it in 
the epigastric region. In a case which occurred in the Meath 
Hospital, it presented itself in the epigastrium, a little to the right of 
the mesial line. Again, in severe cases you may have the whole 
of the liver filled with bile, and having a distinct fluctuating feel, 
not produced by the existence of pus in that organ, but from the 
enlargement of its ducts, ichich are goiged with bile. In one case 
mentioned in the Medico-Chirurgical Transactions, this curious cir- 
cumstance occurred. So far, then, as diagnosis is concerned, posi- 
tion appears to be of very little consequence ; but when we have 
this, in addition to the other circumstances mentioned, it will tend to , 
give additional certainty to our diagnosis. In all cases on record 
where there was distended gall-bladder, the patient laboured under 
jaundice, except in that which I have detailed in the early part of .' 
this lecture ; but perhaps if our patient had lived longer, he would ' 
also have had jaundice. 

There is one disease more which may be, and I believe has been, 
confounded with acute hepatitis and abscess of the liver. This ;• 
affection, which has not been sufficiently noticed by authors, is in- ' 
flammation and abscess of the abdominal parietes over the hepatic 
region ; and this is a very singular disease. It is sometimes trifling, \ 
but I have seen a patient die of it. With the original nature of this 
disease I confess that I am not at all well acquainted ; nor can I t 
say whether the inflammation first attacks merely external parts, or 
whether it is a primary affection of the liver, and that the external 
parts take on diseased action from sympathetic irritation. In such 
cases we frequently observe many of the symptoms of inflammation 
of the liver, as pain, tenderness, biliary derangement, foul tongue, 
and morbid stools, with a tumefied state of the integuments. After 
these symptoms have continued for some time, the tumour increases 
in size, becomes softer, and matter forms. You give exit to the 
pus by opening the abscess with a lancet, and the patient gets well. 
This occurrence I have frequently witnessed. From a considera- 
tion of all the circumstances, it strikes me that in this disease the 
first morbid action in all probability commences in the liver itself, 
and that the external inflammation is an example of the strong 



HEPATIC ABSCESS. 



183 



sympathy which subsists between disease of deep-seated parts and 
! integuments which cover them. Of this fact you have several 
J illustrative instances. In pleuritis we frequently find the integu- 
j menls of the chest remarkably tender on pressure ; and in cases of 
I inflammation of the brain the integuments of the scalp have their 
j sensibility much increased. The same thing occurs in hepatitis 1 
j and in this disease one of the first distinct symptoms is this tender- 
: ness of the superincumbent skin. Now, you can conceive that, 
I if this morbid sensibility of the investing parts should increase, 
| in place of having some pain and tenderness, accompanied by swell- 
ing, we may have suppurative inflammation set up in these parts; 
j and that, under such circumstances, the inflammation may leave 
the internal organ where it first existed, and be thrown upon the 
j external parts in its vicinity. It strikes me that this is not unfre- 
j quently the case in this curious affection. In the case of this 
j disease which I have seen prove fatal, the following circumstances 
were observed : — evident symptoms of inflammatory fever ; pain and 
j tenderness in the region of the liver, followed by the appearance of 
a tumour; which became fluctuating, was opened, and a quantity of 
matter discharged with considerable relief to the patient. She left 
the hospital, but returned again in about a fortnight or three weeks, 
with an enormous tumour in the same place, which was again 
opened, and a vast quantity of purulent matter evacuated. Though 
the matter continued to flow out freely, she did not recover strength ; 
I and on inquiry it was found that before her second admission she 
had spit up some blood. One day, while dressing the abscess, the 
gentleman who attended her observed that when she coughed air 
passed out through the wound, proving the existence of a fistulous 
communication with the lung. On examination after death we 
found an abscess, the base of which rested upon the peritoneal sur- 
face of the liver, without engaging its substance. From this the 
matter had made for itself a double passage, one externally, the 
other through the diaphragm and pleura into the substance of the 
lung. This was the only case in which I have seen this disease 
prove fatal; and in it death appears to have been caused by the 
extent of the disease, and by the abscess opening into the pleura and 
lung.* 

1 * [One of the most extraordinary instances of the termination of hepatic abscess is 
recorded in the Eclectic Journal of Medicine for January, 1839. It was a discharge 
through the colon downwards and the lungs upwards. The subject of the case 
was, at the time, under the care of Dr. Colledge, at Macao, China. He had suf- 
i fered from hepatitis from the 6th August, 1836, in Canton, to the last of the month, 
j for which he had been bled, leeched, and blistered, and had taken calomel freely. 

From the 1st to the 13th of September he was occasionally leeched, took small 
i doses of calomel, with rhubarb and castor oil, and enemata, and was subjected to 
j counter-irritation from blisters and tartar emetic ointment. On the 13th, the 
| patient felt himself all on a sudden relieved — was sensible of something having 
I given way within him. On examining his intestinal discharges the next day, a 
j very considerable quantity of purulent matter was seen in them and in those 
which he passed for some days after — warranting the opinion that had been held 



184 



STOKES'S THEORY AND PRACTICE. 



LECTURE XVII. 

Aneurism of the hepatic artery — Distension of the liver with bile — Treatment of he- 
patitis — Employment of mercury — Symptoms of suppuration — Dr. Graves's operation 
for giving exit to matter in hepatic abscess — Rupture into the peritoneum — Chronic 
hepatitis — Complication with disease of the heart — Embryonary state of the liver. 

You may remember, in one of my past lectures I alluded to a 
case of aneurism of the hepatic artery, of which I had procured a 
preparation : to-day I shall be able to exhibit to you the morbid 
appearances in this very remarkable case. It would appear that 
aneurism of the hepatic artery is an exceedingly rare circumstance. 
At a late meeting of the Academy of Medicine of Paris, a specimen 
of aneurism of the hepatic artery was presented to the society ; and 
that celebrated pathologist, Cruveilhier, stated that it was the first of 
the kind he had ever seen. I wish to bring this preparation before 
you, not merely from the interest which its rarity excites, but also 
because the disease, in this instance, produced that distended 
condition of the gall-bladder to which I drew your attention 
on a former occasion, and which, in this case, was recognised 
before death. The gall-bladder formed a distinct pyriform tumour, 
situated a little above the iliac fossa, and the patient was deeply 
jaundiced. I shall state, from recollection, what I know of the 
details of this case. The patient was brought into the Meath 
Hospital, labouring under jaundice, which he stated to be of some 
days' standing. He was thin and weak, and when questioned | 
respecting his age, he said he was thirty-five, but he appeared to 1 
be upwards of fifty. His habits he described as being uniformly 
temperate and regular. Some years before he had suffered from 1 
an attack of apoplexy, but after this had enjoyed good health, until 
the occurrence of the present illness, which began with vomiting 
of blood, and which continued for some days and then yielded to i 
medical treatment. He now experienced a loss of appetite, became ' 
quite dyspeptic and constipated; he also began to lose flesh, and ) 

of an abscess having formed in the liver. For ten or twelve days from this time I 
he improved considerably, when another return of the symptoms took place. The ) 
same remedies were applied as before, together with anodyne fomentations, but , 
with the same want of success. He got daily worse, and serious apprehensions i 
were entertained regarding his recovery, when, on the 4th of October, he expe- 1 
rienced another sudden change for the better. But this time the abscess burst 
into the thorax instead of the colon, and the matter was discharged by expectora- > 
tion. He soon became convalescent and sailed for England. In a letter from St. f 
Helena, on his way home, dated February 7th, 1837, he says that " he was gaining 
strength and flesh, and enjoyed the cool weather at sea amazingly." 

At Berhampore (Hindostan), Dr. W. O'Shaugnessey opened the body of a sol- 
dier, in 1831, who died of phthisis. In this subject there was found adhesion by \ 
cicatrix, evidently caused by an old abscess, to the diaphragm and lungs, and f 
another to the colon. Dr. O'S. was not able to obtain the previous history of the 
case, but he had never suspected liver disease — in fact there was none at the time ' 
of his last illness. 



! 



ANEURISM OF THE HEPATIC ARTERY. 185 



under these circumstances applied at a dispensary, where he got 
various remedies without any benefit. Some time after this he 
| observed, on getting up one morning, that his arms and legs looked 
rather yellow ; on the following day he had a decidedly bilious 
tinge with yellow vision, and in this state he entered the Meath 
I Hospital. On admission he presented symptoms of general jaun- 
! dice ; the urinary secretion was deeply coloured ; the skin, eyes, 
! and nails yellow ; the stools white and without any trace of bile. 
1 On examining the abdomen, the liver was apparently greatly in- 
j creased in size ; in the epigastric region there was a tumour of 
considerable dimensions ; and in the iliac fossa we observed a 
| separate pyriform tumour, which could be traced up to the edge of 
the enlarged liver. I mentioned at that time to the class, that there 
| was something about the case which I could not understand. The 
| disease was of inconsiderable standing ; the patient had, a short 
: time previously, been in a state of good health, and yet, reasoning 
from analogy, this hepatic tumour could only have occurred as the 
I result of chronic disease. It must have been the consequence of 
| disease more or less chronic, and yet the history of the case was at 
1 variance with the idea of its chronicity. After some time the 
patient got miliary eruption, then petechial spots ; he continued in 
a low and weak state, and nothing did him any good. On the 
morning of the day of his death he did not appear worse than 
usual ; he answered our inquiries respecting his health in his 
ordinary manner; in the evening he sat up in bed gasping for 
' breath, with a look of extreme distress ; he then leaned back on 
i his pillow and expired. 

On opening the peritoneum we found a vast quantity of blood 
effused into its cavity, and my first impression was that it was 
aneurism of the abdominal aorta. On closer inspection, the aorta 
proved healthy, and the aneurismal tumour was found to be con- 
nected with the hepatic artery ; this had ruptured close to the gall- 
bladder, and its contents had been effused into the cavity of the 
peritoneum. We now found that the cause of the jaundice had 
been the pressure which this tumour had exercised on the biliary 
ducts. In consequence of the obstruction to the flow of bile, the 
ducts of the liver were dilated to an enormous extent ; some of 
them were capable of admitting the largest-sized finger. This 
dilation affected not only the larger trunks, but even extended to 
their most minute ramifications, even up to the surface of the liver; 
| and here we found that the biliary tubes were dilated into sacs, 
some of which were as large as a hazle-nut. When these pouches 
j were punctured the bile gushed out freely. A similar condition of 
! the ducts has been noticed by Mr. Lloyd as existing in connection 
I with obstruction of the biliary duct, from disease of the head of the 
! pancreas, in his paper on Discharges of Fatty Matter from the 
| Bowels. (See Med. Chir. Trans.) I have got the preparation of 
I this singular disease before me, and I regret that in one respect it 
is defective, inasmuch as it does not show satisfactorily the condi- 

17 



186 STOKES'S THEORY AND PRACTICE. 



tion of the biliary ducts. A portion of the preparation which 
exhibits this appearance I gave to Dr. Houston, the curator of the 
Museum at the College of Surgeons, and lam sure that he will 
give admission to any gentleman who is anxious to examine it. 
This preparation, gentlemen, is too large to send round. It exhibits 
the hepatic artery with its aneurismal tumour, and the opening by 
which the artery communicates with the aneurismal sac. Here is 
the place in which the rupture took place, and here is the gall- 
bladder greatly extended and thickened in its coats. 

Here, then, we have a new cause of jaundice, where the disease 
is the result of the pressure of an aneurismal tumour of the hepatic 
artery — a cause which has hitherto been unnoticed by writers on 
jaundice. The great interest of this case consists in this, that dis- 
section explained the difficulty which I felt in making the diagnosis 
at first, for it showed that the hepatic tumour was formed, not by 
an hypertrophied, but by a distended and displaced liver. It 
proved that it was formed, not by a process of chronic growth, but 
by the rapid formation of an aneurismal swelling and the conse- 
quent obstruction of the gall-bladder, accompanied by distension of 
the liver itself. With recent symptoms, then, we had, in this case, 
an enormously large liver, not the product of acute inflammation, 
hut of distension of all the biliary ducts up to their most minute 
ramifications, and arising from mechanical obstructions. As far 
as it goes, this case appears to me to be perfectly unique. 

Let us turn now to the treatment of acute hepatitis. It is unne- 
cessary for me to say, that in all cases of acute visceral inflamma- 
tion, in the healthy subject, the first consideration is bloodletting, 
either general or local. In the early period of acute hepatitis, all 
authors have agreed in strongly recommending the use of the 
lancet; and there can be no doubt that when the disease is in its 
early stage, and the patient robust, the practitioner who omits 
employing these measures must be culpably negligent. It should 
always be borne in mind that the liver is an organ of paramount 
importance to life. There are two circumstances, also, which are 
in favour of bleeding in the case of an acute hepatitis — there is 
less chance of its being complicated with typhus fever, and general 
bleeding exercises a powerful influence over the acute inflamma- 
tions of parenchymatous organs. Hence we bleed with greater 
advantage in a case of acute hepatitis than in the inflammation of 
mucous membranes. Our first bleeding should be large, and such 
as will make a decided impression, and it will frequently be neces- 
sary to bleed a second and even a third time if the disease be very 
acute and the constitution strong, taking care to diminish the 
quantity at each successive bleeding, and to watch its effects. I 
have here to make one remark — that general bleeding is not the 
same heroic remedy, nor has it the same decided influence in ar- 
resting acute hepatic inflammation, as in checking pneumonia. 
A copious detraction of blood has, under favourable circumstances, 
often succeeded in completely removing an attack of pneumonia, 



ANEURISM OF THE HEPATIC ARTERY. 187 

and the patient has recovered without the employment of any other 
j remedial measure; but acute hepatitis is seldom or never cut 
I short in this way. Still venesection is of the greatest importance ; 
| and if it were performed merely with a view of preparing the 
patient for leeching and other depletive measures, its advantages 
I would be unquestionable. I would recommend you, therefore, 
when you meet with a case of hepatitis in the early period, first to 
1 bleed freely, or in such a manner as to make a decided impression 
, on the symptoms ; next, to empty the bowels by prescribing a pur- 
| gative draught, assisted by an enema ; and, lastly, to cover the 
region of the liver with leeches. You will find great advantage 
j in employing your therapeutic means in this order; for if you begin 
with leeches before you have had recourse to venesection, or the 
j use of purgatives, your practice will not be so scientific, nor will 
j your success be so complete. Bleeding, purgation, leeches, and 
the application of cupping-glasses over the leech- bites (is necessary) 
will give you breathing time; and, after the lapse of twelve or 
I fourteen hours, you will find that all symptoms of urgent danger 
! will have passed away. During the progress of the case, the 
remedy which I should principally rely upon is local bleeding, fre- 
quently repeated. If you apply thirty leeches to-day, I would not 
have you repeat them to the same amount to-morrow; but you 
might, perhaps, apply fifteen or eighteen, and the next day ten or 
twelve. By proceeding in this way you will find a great abate- 
I ment in your patient's symptoms ; and I know of no circumstance 
which, taken singly, proves the value and benefit of your treat- 
ment so well as the diminution of the hepatic tumour, which you 
can accurately and satisfactorily ascertain by means of the plexi- 
meter. When you find a gradual subsidence of swelling, I think 
you may be pretty sure that, even though the other symptoms ex- 
hibit little or no improvement, the hepatitis is on the decline, and 
will soon be removed entirely. 

You have all, I am convinced, heard a great deal of the use of 
mercury in hepatitis ; and there appears to be in the minds of most 
medical men a strong connection between mercury and all dis- 
eases of the liver. So far has this impression gone abroad, that to 
some practitioners it would appear perfectly heterodoxical to think 
of attempting to cure an hepatic inflammation without this accredited 
panacea. I must however confess that it is my belief that several 
! cases of hepatic inflammation may be cured without it ; and, if this 
i be true, as I am convinced you will find by experience, it is so 
I much the better for the patient. I do not mean to depreciate the 
j value of this powerful remedy in making this assertion ; — it is un- 
j doubtedly a useful adjuvant, but it is only an adjuvant. It is de- 
! cidedly secondary and inferior to general and local antiphlogistics, 
| followed by counter-irritation ; and you should always bear in 
I mind, that if you wish to bring about the full action of mercury on 
j the system, you must precede its employment by means calculated 
| to reduce the intensity of local inflammation. By premising general 



188 



STOKES'S THEORY AND PRACTICE. 



bleeding, leeching, and purgatives, you give the mercury an oppor- 
tunity of exerting a decided influence on the salivary glands ; and 
in such cases it is that the most unequivocal advantage is derived 
from it ; for, as I have observed in a former lecture, salivation 
appears often to be the result of the reduction of inflammation to a 
certain degree, and not its cause. 

In all cases of hepatitis occurring in delicate females, but parti- 
cularly in persons of low, scrofulous constitutions, endeavour to 
dispense with the use of mercury if possible.* You will have con- 
siderable difficulty in divesting yourselves of early prejudices, and 
combating those of others ; but when you have an opportunity of 
acting for yourselves, I would have you make trial, and you will 
find that many cases are curable without mercury. If, after having 
regularly and carefully employed the means recommended, you 
perceive that two or three days pass without any improvement in 
your patient's symptoms, and that the hepatic tumour remains un- 
diminished, then indeed you may have recourse to mercury. But 
if you have been so fortunate as to have struck a decided blow in 
the commencement, and that the case is going on well, I would 
ask, why should you expose your patient to the misery and danger 
of salivation ? I am not by any means opposed to the employment 
of mercury in cases of liver disease; on the contrary, if we com- 
pare inflammation of the lungs, brain, and liver, with respect to the 
power which it has over each, I believe that it is much more appli- 
cable to cases of hepatic inflammation than it is to either pneumonia 
or cerebritis. 

There is nothing more common than a complication of disease of 
the liver with disease of the upper part of the digestive tube ; and 
here you will find that calomel will frequently cause great irritation 
of the bowels, vomiting, and increase of fever. Under such cir- 
cumstances, you must omit the internal use of mercury, and have 
recourse to frictions, directing your patient to rub in a dram of 
camphorated mercurial ointment every six or eight hours until the 
gums are affected. A very good auxiliary means is to place a 
dram of the mercurial ointment in the patient's axilla, and leave it 
there ; the action of the arm will, to a certain extent, answer all 
the purposes of friction. Dr. Graves is much attached to this mode. 
Where you have employed blisters, you may cut off the cuticle, and 
dress the raw surface with mercurial ointment. This also will 
contribute materially to produce the intended effect on the system. 
With respect to blisters, the same rules are to regulate their appli- 
cation as I have mentioned before, when speaking of the treatment 
of gastro-enteritis, namely — that they are not to be used until 
active antiphlogistic treatment has been employed ; for it is then, 
and then only, that the stimulus of a blister can be useful. I believe 
it is seldom necessary, or even safe, to apply a blister before the 

* [In cases of this description I have directed the iodine (Lugol's solu tion 
and the hydriodate of potassa in solution) with excellent effect. — BJ 



J 



ANEURISM OF THE HEPATIC ARTERY. 



189 



third or fourth day in cases of acute inflammation of the liver. The 
physician who purges to-day, and blisters to-morrow, and bleeds next 
day, is a very injudicious practitioner indeed ; he should bleed first, 
then purge ; and having by these means reduced the symptoms 
of active inflammation, he may proceed to the use of blisters with 
advantage. 

It is unnecessary for me to remind you that you must enjoin a 
strict antiphlogistic diet in all cases of acute hepatitis. Recollect 
the powerful influence which all dietetic stimulants exercise, not 
only over the digestive canal and general system, but also over the 
liver ; bearing this in mind, you will, for the first few days, keep 
your patient on ^ water and slop diet, and then on a mild farinaceous 
food and chicken-broth. 

But suppose that after all this, after having employed all the re- 
sources of the science and art of medicine, your patient becomes 
gradually weaker, his face pale and expressive of much constitu- 
tional suffering, his skin flaccid and bedewed with perspiration, his 
pulse small, rapid, and compressible ; that the hepatic tumour in- 
creases in size, and when you throw aside his bed-clothes, the 
whole of the right side appears manifestly enlarged ; and, if the 
bowels are empty, you see the hepatic tumour extending far down- 
wards into the abdomen ; in addition to these symptoms, suppose 
the patient has had shivering fits, not only once but repeatedly ; 
that his perspirations are profuse, and have a sour smell ; that his 
tongue is dry and glazed ; that his cheeks are hollow, and some- 
times present a circumscribed flush ; and that he is low, weak, and 
restless. Under these circumstances you may be sure that suppu- 
ration is commencing, or has been already established. ; and the 
question is, what are you to do ? You must change your hand 
you must give up antiphlogistics, you must omit the employment 
of all measures which have a tendency to reduce strength, you 
must prescribe a light nutritious diet, and anodynes to relieve irri- 
tation. When suppuration is fully established, the next considera- 
I tion is, in what direction the contents of the abscess may escape ; 
and here I need not remind you that it is much better that the 
abscess should open externally, through the integuments of the 
abdomen, or into some cavity having an external communication, 
i rather than into a shut sac, as in the latter case it is almost certain, 
and often immediate death. At this period of the case it will be 
proper to support your patient's strength by allowing him wine, 
! increasing the quantity if the hectic symptoms threaten to run him 
! down, and taking care that his diet be nutritious and of easy 
1 digestion. You will also take care to relieve his sufferings, and 
I irritation attendant on the disease, by the judicious employment of 
I opiates. 

When after some time the tumour becomes more elevated and 
i distinct, the pain concentrated in one particular part of the liver, 
j and the abscess is evidently pointing towards the surface, the ques- 
tion then is, whether we shall open it and give exit to the matter. 

17* 



100 



STOKES'S THEORY AND PRACTICE. 



and how this may be best accomplished. That the contents of the 
abscess should be evacuated as speedily as possible is true, but the 
consideration is, how far it can be done with safety. Now, I beg 
your attention to this point, as it has not been sufficiently attended 
to in works on the practice of medicine. Recollect what the ana- 
tomical condition of the parts is under such circumstances, and that, 
in order to get at the matter, you have to pass through a serous 
cavity. It is obvious that if you make an incision into the tumour 
through the peritoneum, and if this be in a state of health, and 
without any adhesions between its layers in the situation of your 
incision, you run the risk of having the contents of the abscess 
effused into the peritoneal sac, and you know tha^ this is almost of 
necessity fatal. The condition then for success is, the circum- 
stance of adhesion taking place so as to prevent the matter from 
getting into the peritoneum. 

Well, it seems to be a very simple thing to give exit to the 
matter of an hepatic abscess which presents a distinct pointing. 
Persons will say, adhesion has formed long since, the integuments 
are swollen and painful, the matter has crossed the peritoneum and 
lies close under the skin. Here, however, is a curious fact ; of all 
the serous membranes in the body the peritoneum is that which is 
least liable to general or partial adhesions, and it is well known 
with respect to hepatitis with suppuration, that you may often have 
abscess so large as to form a distinct tumour on the surface, which 
shall be fluctuating, discoloured, and painful, and with all frnese 
conditions, so favourable to the notion of matter being actually 
under the skin, the patient dies, and on dissection we find not ihe 
slightest trace of adhesion. If you plunged a trochar or abscess- 
lancet into the tumour, what would be the consequence ? — death 
by peritonitis. Dr. Graves and I, in our report of the cases of 
hepatic abscess which occurred in the Meath Hospital, were the 
first who drew the attention of the profession to this interesting 
pathological fact, and subsequently to this, Mr. Annesly who has 
vast experience in hepatic abscess, stated that in his practice he 
found that the existence of adhesion between the layers of the peri- 
toneum in the vicinity of the abscess, even after swelling, tenderness, 
and discoloration of the integuments, is by no means a necessary 
consequence. 

It appears then to be quite certain, that the opening of an hepatic 
abscess is a matter of considerable nicety, and requiring a great deal 
of caution. The best mode of proceeding which can be adopted is, 
in my opinion, that which has been recommended by Dr. Graves, 
and which is founded on the most accurate pathological views. He 
makes an incision through the integuments, over the most promi- 
nent part of the tumour, and carries it through the cellular sub- 
stance, fat, and muscular tissue, until the peritoneum is nearly laid 
bare, and there he stops. The wound is then kept open by plug- 
ging it up with lint, and after some time the abscess bursts in this 
situation with perfect safety to the patient. This operation was 
performed under his direction, for the first time, in a case of abscess 



ANEURISM OF THE HEPATIC ARTERY. 



191 



where there was no distinct pointing. It was the first operation of 
| the kind, and every one who witnessed it waited with anxiety for 
the result. Five or six days passed away without any appearance 
j of matter ; but about this period the abscess began to point, shortly 
afterwards there was a large gush of matter through the wound, 
and the patient recovered perfectly in three weeks. Since that 
| time the operation has been perfomed on two patients with success 
j and safety. In the case of one patient it was performed twice at no 
I very considerable interval. 

Now, I believe you are all aware that in cases of deep-seated 
! collections of pus, it is of the greatest importance to remove the 
obstruction to its exit externally, and that matter will always point 
towards the place where there is the least resistance. The per- 
! formance of this operation not only tends to remove the resistance, 
! but also has this advantage, that the existence of irritation in the 
neighbourhood of the abscess, and immediately over the peritoneum, 
has a strong tendency to produce adhesion at this point; a circum- 
j stance which I was able to verify in a fatal case, in which the 
j abscess had pointed, but never burst. In this case we found on 
! dissection six or seven small tumours near the surface of the liver, 
without any traces of adhesive inflammation in the peritoneum over 
them, but over the situation of the tumour, in the direction of which 
the incision had been made, there was a considerable quantity of 
organized lymph, and the two layers of the peritoneum were closely 
adherent. That this effusion of lymph had not been accidental, is 
I rendered probable by the rarity of its occurrence, from not being 
observed in other cases in which an operation had not been per- 
formed, and lastly, from the success of the operation in those cases 
in which it had been employed. I would advise you, therefore, in 
all cases of hepatic abscess showing a tendency to point, but parti- 
cularly if this pointing be distinctly towards the surface, to make an 
incision down to the peritoneum, fill up the wound with lint, and 
you will often succeed in causing the abscess to break externally, 
and without any danger to your patient. 

With respect to the bursting of an hepatic abscess into the cavity 
of the peritoneum, I have stated before to you, that it is almost 
necessarily fatal. I say almost, because I have seen two cases of 
this termination, of which one recovered completely from the 
peritonitis, and the other lived eight or nine days after the dis- 
charge of matter into the peritoneum, and on dissection it was 
found that a process of cure had been going on. The first of these 
cases was that of a young woman who had a vast chronic abscess, 
j An attempt was made to make this open externally, by destroying 
| the soft parts over it with caustic, but this not succeeding, a lancet 
i w T as introduced through the eschar made by the caustic. The 
i patient was immediately afterwards attacked with severe pain in 
| the abdomen, and distinct symptoms of peritonitis. As she was 
very weak and emaciated, Dr. Graves, under whose care she was, 
gave her opium in full and repeated doses, allowing her the free 
use of wine and porter; no blood was drawn, no depleting measures 



| 



192 



STOKES'S THEORY AND PRACTICE. 



of any kind used, but everything done to support strength and 
relieve irritation. Under these circumstances (wonderful to relate) 
she recovered from the peritonitis. She afterwards sunk from the 
abscess, and on dissection we found that the peritoneal cavity 
was obliterated, just as the serous investment of the testicle has its 
opposed surfaces glued together after an operation for the radical 
cure of hydrocele. In the other case, the patient lived eight or nine 
days after the occurrence of symptoms of peritoneal inflammation. 
On dissection, we found a large quantity of transparent lymph ef- 
fused on the surface of the peritoneum, in the substance of which 
several large blood-vessels had been developed. 

The principles of treatment in a case of this dreadful accident is 
to support strength and remove irritation, laying aside all antiphlo- 
gistics. I am sure that, under such circumstances, the ordinary 
modes of treating peritonitis are inapplicable and useless. As I shall 
return to this subject when I come to speak of peritonitis, I shall 
here merely state, that the treatment of such a case as this is to be 
conducted upon the same principles as peritonitis, produced by rup- 
ture of the intestine, or a perforating ulcer. 

Gentlemen, I shall occupy your time briefly in treating of 
chronic hepatitis. You will find a full description of the symptoms 
of this disease in almost every book on the practice of medicine, 
and it is unnecessary for me to detain you with details of this 
kind. If we are to judge from British practice, chronic hepatitis is 
a very common disease, and, if we look to the practice, it is an affec- 
tion under which half the community labour. I believe, indeed, 
that the chronic form of this disease is much more frequently 
observed in this country than the acute, but still I think it is any- 
thing but a disease of universal prevalence. 

I shall not, as I said before, take up your time in stating what 
you will find in any medical work ; I shall merely mention that in 
chronic hepatitis we have generally derangement of the bowels, 
chiefly affecting the stomach and upper part of the digestive tube, 
and in addition to this w 7 e have more or less pain, tenderness, and 
swelling in the region of the liver, and often dulness of sound over 
the lower part of the right side. When we meet with this train of 
phenomena, we say that the patient has the symptoms of chronic 
hepatitis. But no one under such circumstances could undertake 
to say whether the patient will die of hypertrophy or atrophy, of 
cancer or hydatids, of tubercles, or of fatty discharge, or of any 
peculiar disease of the liver. There is another point, too, of which 
I am anxious you should be aware. Chronic hepatitis is a disease 
which has been, and is, frequently confounded with various other 
affections ; — with scirrhus of the pylorus, with chronic disease of 
the duodenum, with chronic disease of the pleura, and empyema of 
the right side. There is one circumstance which you should bear 
in mind when you are in doubt with respect to a chronic hepatitis, 
that one, two, or three of these affections may occur in connection 
with chronic inflammation of the liver. For instance, a patient 
labouring under chronic hepatitis may have also at the same time 



ANEURISM OF THE HEPATIC ARTERY. 



193 



empyema and disease of the duodenum. I believe the subject of 
disease produced, as it is said, by contiguity in separate organs, 
has not as yet been sufficiently investigated, and that our know- 
ledge on this important point is extremely scanty. 

There are two circumstances connected with this part of the 
subject, on which I shall say a few words. One common error is 
that of confounding affections of the heart with those of the liver, 
and this I regret to say is an error of very serious consequence, and 
one which is frequently observed in the consultations of medical 
practitioners. A patient complains of palpitations, a physician is 
called in, and pronounces the disease to be hypertrophy of the 
heart ; another is called in, and gives it as his opinion that the 
liver is affected ; a third is summoned, and says that both the liver 
and heart are diseased. In such cases you should always make a 
careful examination, and weigh well the circumstances of the case 
in your mind before you venture to pronounce an opinion. In the 
first place, you are to recollect that organic disease of the heart may 
produce disease of the liver. Secondly, that disease of the liver 
(though not so often) frequently brings on morbid affections of the 
heart and nervous palpitations. Thirdly, that these affections act 
to one another reciprocally as cause and effect. If a person has 
disease of the heart, the current of the circulation through that 
organ is obstructed, and you may have disease of the liver, not as 
the result of any original affection of that organ, but as the effect of 
chronic obstruction to the passage of blood through the heart 
The consequent congestion and disease of the liver may, in such a 
case, be reflected on the digestive tube, and this in turn may re- 
act on the heart. The heart sympathizes then with the irritation 
of the digestive tube ; we have nervous palpitations, and if these 
continue for a length of time, we have the disease of the heart 
increased. Again, suppose a patient has chronic disease of the 
liver, causing more or less obstruction to the circulation ; the heart 
begins to sympathize, palpitations commence, go on increasing, and 
finally terminate in hypertrophy of the heart. The mischief does 
not stop here ; the effects of obstruction extend to the vena cava 
hepatica, this in turn reacts on the liver, and we have in this way 
a curious train of phenomena ; first liver disease, then heart disease, 
and lastly, liver disease again. Let me once more impress upon 
you that, under such circumstances, you cannot be too diligent 
in making an examination, or too cautious in pronouncing an 
opinion. 

There is another thing connected with hepatic disease which you 
should be aware of. A patient, labouring under the following train 
of symptoms, comes to consult you ; — he has pain in the right 
hypochondrium, loss of appetite, deranged bowels, morbid stools, a 
dirty bilious hue of countenance, and, in fact, all the symptoms of 
diseased liver. You examine the liver and find it very much 
tumefied, in fact, its size is so much increased that you would at 
once be inclined to say that it was extensively diseased. Now, 
there are some cases of great tumefaction of the liver accompanied 



194 



STOKES'S THEORY AND PRACTICE. 



with more or less of the symptoms of hepatic derangement, and yet | ! 
in such cases you may have no disease of the liver at all, at least i 
none of the ordinary forms of hepatitis : these are cases in which 1 
there exists, in adults, a persistence of the embryonary condition I 
of the liver. Jf we compare the condition of this organ in the I 
infant and in the adult, we find many essential points of difference. 
In the infant it is comparatively large, and, as it were, hypertro- : . 
phied ; it descends far below the margin of the ribs, and occupies 
a large portion of the abdominal cavity. On the other hand, if 
we examine its state in the adult, we find that it has shrunk 
beneath the short ribs, and that its size and dimensions are com- 
paratively much reduced. Now this physiological atrophy of 
the liver is a natural and healthy process. There are certain \ 
individuals, however, in whom this change does not take place, ) 
and who grow up with the liver bearing the same proportion to 
the other organs as it did in the fatal condition. This curious 1 
condition is one of the varieties of arrest of development, and is, in I 
almost every instance, observed in those persons whose constitu- - 
tions present that train of phenomena to which the term scrofula > 
has been applied, and which (if I have time) I shall show you is t 
explained, or at least great light is thrown upon it, by the theory 1 
of arrest of development. In such subjects the tumefaction of the 
liver is by no means a measure of actually existing disease. If 
you were to suppose this tumefaction of the liver to be the product • 
of actual recent disease, and proceed to treat the patient in the same 
way as you would treat a case of hepatitis in the healthy subject, 
you would not only do no good, but, in all probability, a great deal 
of mischief. I know the case of a gentleman, in the enjoyment of [ 
good health, who has this tumefaction of the liver to a very great 
degree. He is of a thin spare habit of body, with a full, round, 
and prominent belly ; he is pursuing the avocations of an active 
profession, and yet you will hardly credit me when I say that his \ 
liver extends below the umbilicus, and close to the anterior superior jj 
spine of the ileum ; yet he is very active, and to all appearance a 
healthy man. You will often meet with this condition of the liver |i 
in children who are attacked at an early age with symptoms of 
tabes mesenterica. 1 

At the next lecture I hope I shall be able to finish diseases of 
the liver, and proceed to the consideration of other affections of the 
system. : 



LECTURE XVIII. 

Treatment of chronic hepatitis — Neuralgia of the liver succeeding hepatitis — Connec- 
tion of hepatic with gastro-intestinal disease — Modes of transmission of disease from 
the mucous surface of the liver — Phlebitis of the vena porta — Obstruction of this 
vein — Case of pulmonary, hepatic, and intestinal fistulae — Hepatic neuralgia. 

We now come to the consideration of the treatment of chronic 
hepatitis. It is of great importance, in a case of this kind, to place 



TREATMENT OF CHRONIC HEPATITIS. 



195 



I your patient under such circumstances as will insure the full and 
favourable action of the remedies employed. The use of wine, 
I spirits, and all kinds of exciting food, must be laid aside; the 
: patient must not use anything capable of producing fever during 
the process of digestion. So long as any kind of food or drink pro- 
J duces uneasiness and sensations of heat and fulness, you may be 
I sure that it will do more harm than good. Give him what will 
' support his strength without exciting the vascular or nervous 
' systems during the process of digestion. 

You must next prevail on your patient to give up the use of 
active purgatives by the mouth. This is a point which you should 
j strongly and firmly insist upon, as, in consequence of the ordinary 
costive state of the bowels which accompanies chronic inflammation 
| of the liver, the patient is generally in the habit of having recourse 
j to those temporary and hurtful remedies. It is the same thing in 
cases of chronic hepatitis as it is in chronic gastritis; you will find 
the subjects of these diseases taking different purgatives every day. 
| Break your patient of this practice, if possible ; you will have some 
l difficulty in doing so, for he has been long habituated to it, and you 
must exercise all your authority in putting a stop to the pernicious 
habit. Instead of purgatives by the mouth, make him use every 
day an emollient injection. You may, if necessary, give occasion- 
ally, mild laxatives by the mouth, as Rochelle salts, manna, castor 
oil, or something equally mild, and in this way you will be able to 
I secure a regular alvine discharge, once in the twenty-four hours at 
least. But where there is considerable pain and tenderness in the 
region of the liver, this plan alone will not be sufficient; you must 
i apply relays of leeches, a practice which has a most admirable 
effect in chronic hepatitis. I would advise you to apply cupping- 
glasses over the leech-bites; by doing this, you get as much 
blood as you wish, and you will generally save your patient from 
the annoyance of an oozing hemorrhage. When piles exist, it will 
be useful to apply leeches to the anus, followed by the hip-bath. 
But I have no hesitation in saying, that, as a general mode of reliev- 
ing hepatic disease, the application of leeches to the right hypochon- 
drium is far preferable in every point of view. You may in the next 
place, have recourse to blisters ; and I have frequently employed 
I blisters, alternately with leeches, with the best results. Tartar 
emetic ointment, in the form which I have already mentioned, 
croton oil frictions, and other modes of counter-irritation, will assist 
materially in bringing about a successful termination. But these 
must be continued long, and used over an extensive surface, 
j In this way, by regulating your patient's diet, keeping his bowels 
open by enemata, or the mildest laxatives, by small and repeated 
. | local bleedings, with counter-irritation, you will frequently succeed 
i j in removing all the symptoms of chronic hepatitis without the use 
lS j of mercury. But if, after having carefully employed all these 
I measures, the symptoms manifest a degree of persistence, if your 
c | patient has not already taken a large quantity of mercury (which is 
t 

\ 



196 



STOKES'S THEORY AND PRACTICE. 



not likely to be the case in this country), and if he be not of a 
scrofulous habit, I see no reason why you should not have recourse 
to mild doses of mercury. For this purpose, nothing answers better 
than to prescribe, once or twice a day, a pill composed of hydrarg. 
c. creta, blue pill, or a small quantity of calomel, combined with 
rhubarb, extract of hyosciamus, and taraxacum. It will be seldom 
necessary to bring on actual salivation ; but if the pain continues to 
be severe, the swelling undiminished, the symptoms obstinate, and 
no contra-indication existing, you may bring him under the influ- 
ence of mercury, and keep him so for a short time. The best 
mode of doing this is to direct him to rub in a dram of the cam- 
phorated mercurial ointment every day ; and if you have employed 
blisters, you can assist the frictions by dressing the blistered surface 
with mercurial ointment. 

Some practitioners are in the habit of substituting the nitro- 
muriatic acid for the mercurial treatment, and there appears to be 
evidence that it is an advantageous mode of practice in these cases. 
The best mode of using this remedy seems to be the endermic ; and 
hence, bathing the feet, or sponging the right hypochondrium with 
the acid, are most recommended in chronic affections of the liver. 
As it is convenient to have a formula for making the nitro-muriatic 
solution, I shall give you the following. Take of strong nitric and 
muriatic acids of each four ounces, and add to these eight ounces of 
pure water. Here you have a sixteen ounce mixture ; of this com- 
bination you may take from two to five ounces, and mix them with 
three gallons of warm water. This, I believe, is the form recom- 
mended by Mr. Annesly. Having placed this solution in a foot 
bath or tub, you should direct your patient to keep his feet in it for 
twenty minutes or half an hour. If the bath be of proper strength, 
it will communicate to the skin a prickling sensation; if not, you 
may increase its strength by adding an ounce or two more of your 
mixture. The same solution will answer for sponging over the 
liver. 

There is no doubt that, in certain cases of chronic hepatitis, this 
remedy has been found decidedly useful, and as its employment is 
unattended with any dangerous or disagreeable consequences, it 
has strong claims to our notice. The cases of chronic hepatitis to 
which it seems to be peculiarly adapted, are, first, those where 
mercury has been used irregularly, or for a long time without any 
benefit, and, secondly, where the patient is of a broken down con- 
stitution, and where you are anxious to dispense with the use of 
mercury, if possible. Here the nitro-muriatic treatment is of 
decided value. I need scarcely remark to you that this acid fre- 
quently acts upon the system somewhat like mercury, producing 
tenderness of the gums and ptyalism. . Such an effect as this, fur- 
nishes us with an example of these cases, in which we find other 
remedies, as well as mercury, producing a decided effect on the 
salivary glands, and exercising a very powerful influence over 
hepatic and syphilitic affections. An interesting fact, bearing on 



TREATMENT OF CHRONIC HEPATITIS. 



197 



this point, is related by Mr. Cox, in his account of his residence on 
the Columbia river. Several of his party, who used a strong decoc- 
tion of the fresh sarsaparilla, were salivated. 

There is one circumstance, connected with the treatment of 
chronic hepatitis, which I believe has not been sufficiently dwelt 
j on. You may have a case in which there was distinct evidence of 
1 chronic inflammation, and where, under the influence of judicious 
! treatment, the signs of inflammation and organic derangements sub- 
! sided, but where severe pain still continues to be felt in the region of 
the liver. The nature of this pain is often mistaken ; it is sup- 
■ posed to depend upon a continuance of inflammation, ivhile it is, 
| in reality, nothing more than a mere neuralgic affection — a rem- 
nant or successor of the former disease, to which the antiphlogis- 
tic treatment is totally inapplicable. Under such circumstances, 
the patient goes from one practitioner to another, taking different 
medicines, and submitting to repetitions of the usual modes of treat- 
ment, but with little or no benefit. Now I have seen, in several 
cases, this symptom yield completely to treatment calculated to 
remove purely neuralgic affections. In a case, lately under my 
care, of a gentleman who had been attacked with enteritis and 
hepatitis in India, and who had taken enormous doses of calomel 
I " for the liver," and of croton oil " for the bowels," this circumstance 
occurred. When first I saw him, he was emaciated, the skin 
yellow, the urine high-coloured, with thirst, costive bowels, and 
great tumefaction in the region of the liver. These symptoms 
1 completely subsided under treatment, but a violent pain, running at 
intervals, continued obstinate. This was rapidly removed by a 
, course of the carbonate of iron, and the use of the belladonna 
plaster. 

It is of great importance, in the treatment of chronic hepatitis, 
to bear in mind the state of the gastro-intestinal mucous membrane. 
You are aware that the disciples of Broussais are of opinion that 
almost all cases of hepatic inflammation are secondary to a gastro- 
enteritis ; that the first morbid action is on the surface of the intes- 
tinal tube, and that it is transmitted from this to the liver, I have 
taken a considerable share of pains in investigating this subject, and 
have examined very carefully the question as to the complication of 
j hepatic inflammation with disease of the gastro-intestinal surface, 
J and the conclusions to which I have come, are the following: — In 
the first place, that most cases, whether of acute or chronic inflam- 
I mation of the liver, present the complication, more or less, with dis- 
\ ease of the intestinal mucous surface, and that in the majority of 
instances there is some degree of actual disease of the digestive 
' tube. It would appear, also, from observation of different cases of 
! hepatitis, that in a great many the affection of the liver has been 
j secondary, and that symptoms of disease of the digestive tube have 
I preceded those of hepatic irritation. But, on the other hand, we 
| must admit that the hepatic affection may be primary ; that the 
j liver has the initiative, and that disease has been subsequently 

18 



198 



STOKES'S THEORY AND PRACTICE. 



propagated to the gastro-intestinal mucous surface. Lastly, we 
may have hepatitis, both acute and chronic, quite independent of 
any disease of the mucous coat of the stomach and bowels. This, 
I believe, is the rarest case ; still it does occur. You observe, there- 
fore, that the doctrine of the physiological school, that all hepatic 
inflammations are secondary to a gastro-enteritis, is not supported 
by the authority of facts. It is therefore wrong to say that every 
case of acute or chronic hepatitis is preceded by gastro-intestinal 
inflammation. Facts have been brought forward to show that not 
only has inflammation of the liver been observed in the simple 
state, and independent of any complication with intestinal disease, 
but that the affection of the liver has distinctly preceded the symp- 
toms of gastro-enteric disease. On the other hand, however, I am 
free to admit that these are the exceptions rather than the rule, and 
that, in the majority of cases, hepatitis is either secondary or com- 
plicated with disease of the gastro-intestinal surface. 

Now, a very interesting question comes to be considered, and 
this is, how does the disease come from the gastro-intestinal surface 
to the liver? Pathology informs us that irritation maybe trans- 
mitted from one organ to another in three different modes. First, 
sympathetically, as through the medium of the nerves. Thus, 
long-continued stimulation of the stomach is reflected upon the 
liver, the liver sympathizes with the suffering organ in its vicinity, 
and finally becomes diseased itself. It is in this way that many 
chronic affections of the liver and stomach terminate in affections 
of the neighbouring viscera and dropsy. The first mode, then, in 
which disease may come to affect the liver from the gastro-intes- 
tinal surface, is by sympathetic irritation. The next mode is sup- 
posed to be the actual transmission of disease along the biliary duct 
from the duodenum to the liver. Inflammation commences in the 
duodenum ; this creeps along the ducts until it reaches the liver, 
which takes on the inflammatory action in its turn. Several persons 
of high authority have supported this view of the question, and 
assert that they can actually demonstrate the passage of inflamma- 
tion along the ducts. Without denying the possibility of this, yet 
I feel convinced that it is rare. I have never been able to discover 
this mode of propagation of inflammation from the duodenum to the 
liver; and it must be remembered that, in the great majority of 
cases of duodenitis, we cannot detect inflammation in the liver or 
its appendages. The last mode by which disease may be trans- 
mitted, is the propagation of inflammation along the course of the 
veins belonging to the portal system, that is to say, there is phlebitis 
of the portal system, and the inflammation travels along the veins 
until it arrives and attacks the liver. That this has occurred, is 
proved. But we may suppose that, in certain cases, disease of the 
liver may result from a phlebitis of the minute mesenteric veins, 
without a continuous spread of inflammation to the larger trunks ; 
just as the lung is affected in cases of phlebitis of the extremities, 
not by actual spread of inflammation, but rather, as Mr. Arnott has 
shown, by the transmission of the products of that inflammation. 



I 



TREATMENT OF CHRONIC HEPATITIS. 199 

Inflammation of the portal veinsis a circumstance which possesses 
great interest in a pathological and practical point of view ; it is a 
curious process, and there are some singularities connected with it 
which have a claim on our attention. In the Clinique Medicale of 
Andral, there is a case given of a patient who, after labouring for 
some time under symptoms of fever and gastro-enteritis, was 
attacked with pain and tension in the region of the liver, followed 
by jaundice. On dissection, marks of inflammation were found in 
the stomach and ileum ; there was also some disease in the colon, 
and the liver was found to be enlarged, and presenting the ordinary 
marks of inflammatory action. On a more minute examination, 
nearly all the mesenteric veins, and the trunk of the porta, were 
discovered to be in a state of intense inflammation ; while, on the 
other hand, the lining membrane of the vena cava was found to be 
in its normal and healthy condition. Here we have a very remark- 
able coincidence between disease of the liver and of the portal 
system. First, the patient had fever, with gastro-enteric inflamma- 
tion, and then pain and tension in the region of the liver, followed 
by jaundice. On dissection, the mesenteric veins and the trunk of 
the porta are found inflamed ; this condition extends to the liver, the 
substance of which is found tumefied, red, and friable. I believe there 
can be no doubt that disease of the liver may be brought on by dis- 

Jase of the abdominal veins, particularly those of the portal system, 
t is a very curious fact, that with symptoms such as many prac- 
titioners would not hesitate to call chronic hepatitis, we may have 
phlebitis, terminating in obliteration of the porta, and even of the 
vena cava. In such cases, nature generally makes an effort to keep 
up the venous circulation ; in consequence of the obliteration of the 
internal abdominal veins, the external ones become enlarged, and 
produce a suplementary circulation to a certain extent, and in this 
way life is prolonged. This drawing, which represents the appear- 
ance of a patient labouring under this form of disease, will give 
you some idea of the matter. You observe the patient's belly is 
enlarged and prominent, his extremities cedematous ; and here you 
see those enormous veins passing along the surface of the belly, and 
keeping up a collateral venous circulation. In the patient, from 
whom this drawing was taken, the porta and cava were obliterated. 
These are the epigastric and other superficial abdominal veins 
which ascend to anastomose with the thoracic, intercostal, and 
axillary veins. 

I shall now relate, as briefly as possible, the particulars of this 
very remarkable case. The patient, who was the subject of it, 
laboured for more than twelve months under jaundice, accompanied 
by wasting of flesh and prostration of strength, but for the first 
eight months he had not been confined to bed. He suffered, how- 
ever, very considerably even at this period, from constant pain in 
the epigastrium and swelling of his feet. Now, in this country, we 
would be very apt, under such circumstances, to say that he was 
labouring under chronic hepatitis. At the end of the eight months 



200 



STOKES'S THEORY AND PRACTICE. 



he became bedridden, and the large veins, which you here see, 
began to make their appearance. Although he was wasting in 
flesh, still he had a canine appetite, and was always complaining 
that he had not enough to eat. This is an interesting fact. It has 
been observed in other cases, and tends to throw some light on the 
share the mesenteric and other abdominal veins have in the process 
of absorption. In tabes mesenterica it has been often remarked, 
that the little patients have generally enormous appetites ; and, as 
it would appear from the same cause, a deficiency of nutritious 
absorption, with this difference merely, that in the disease before 
us it is the veins that are diseased, whereas in tabes mesenterica it 
is supposed to be the lymphatics. But to return to our case. This 
patient had, as I remarked, a very voracious appetite, by indulging 
which, he brought on repeated attacks of constipation and colic. 
He then got diarrhoea and dropsy, for which he was tapped twice 
without any benefit. From observing that there was* in this case 
an extraordinary supplemental circulation, leading to the inference 
that there was obstruction of the deep-seated veins ; from remem- 
bering that the appearance of the patient, and the more prominent 
symptoms, coincided with those of a former case, in which oblitera- 
tion of the porta had been discovered after death ; from these cir- 
cumstances, and the remarkable voracious appetite, JV1. Reynaud, 
under whose care the patient was, came to the diagnosis of phlebitisj 
of the portal system, extending to and affecting the liver; and this 
diagnosis was subsequently confirmed by dissection. He was, 
however, unable before death to explain one symptom which was 
present, namely, infiltration of the lower extremities. You are 
aware, that when the general venous circulation is obstructed 
either in the chest or belly, we have anasarca of the lower 
extremities, but when the obstruction affects only the portal system, 
then we have ascites as the first phenomenon. If you had two 
cases of dropsical effusion, in one of which there was, first, oedema 
of the lower extremities, in the o\he\\ first, ascites, you could thus 
determine where the primary obstruction existed. M. Reynaud 
was at a loss to account for this symptom in the present case, as he 
had not observed it before in the other case, and as the swelling of 
the feet had preceded that of the belly. On dissection, it was found 
that the right branch of the porta had been obliterated by the growth 
of a yellow substance, somewhat like the middle coat of arteries ; 
the same was found to exist in the corresponding hepatic veins, and 
the inferior cava was found obliterated to the distance of three 
inches from the left auricle. The left branch of the porta was per- 
vious, the corresponding hepatic veins much enlarged, and the 
superficial epigastric veins inosculated freely with the intercostal 
and axillary veins. 

The vena azygos was very much dilated ; and, what is extremely 
curious, a large vein was seen to arise from the union of the sub- 
peritoneal branches on the convex surface of the liver ; this passed 
through the diaphragm, and emptied itself into the cava close to 



TREATMENT OF CHRONIC HEPATITIS. 



201 



its termination. Here we have an entirely new vein. It was also 
observed, that the sub-diaphragmatic veins were much increased in 
size, and apparently varicose; these passed through the diaphragm, 
and inosculated with the pericardial and superficial thoracic veins. 
Some of them ran up and opened into the great coronary vein of 

I the heart, which was as large as the crural vein. The remaining 
peculiarities of this curious case were inflammation of the duodenum 
and gall-bladder. The cavity of the latter was half filled with 

; purulent fluid. 

I am fully convinced that I have seen instances of this disease, 
although I was not so fortunate as to have an opportunity of verify- 
| ing the diagnosis by dissection. I have seen patients who had 
j wasting of flesh, pain and tension in the region of the liver, and 
j jaundice, with this singularly varicose state of the external abdo- 
j minal veins ; some of them had ascites ; and I recollect distinctly, 
that in one case the appetite was very great, and the patient had a 
tendency to diarrhoea. I am satisfied that in such cases you would 
) be fully justified in making the diagnosis of obstruction of the portal 
| system; and if, in addition, there was infiltration of the lower 
extremities, there would be a probability that the disease had ex- 
tended to the cava itself. 

Before I proceed to the consideration of a subject to which I have 
already alluded — hepatic neuralgia — it may not be amiss to exhibit 
some specimens of organic lesions of the liver. Here is an example 
of abscess of the liver : — you perceive the softened yellow degenera- 
tion of the substance of the organ ; and here is the cavity of the 
; abscess, in which you may observe a loose slough suspended. This 
portion which surrounds the abscess may be looked upon as a fair 
specimen of the yellow softening of the liver, before its substance 
breaks down into a purulent mass. Here is another specimen 
exhibiting the same phenomena. Here is a very curious example 
of hepatic abscess, which perforated the diaphragm, and made its 
way into the substance of the lung. I regret that the whole of this 
preparation has not been preserved. The rest of the preparations 
before me illustrate chronic disease of the liver. Here is an example 
of the disease which has been called cancer of the liver. Time will 
not permit me to enter into a detail of the pathological circumstances 
of this case. The patient was a female, who had cancer of the 
breast, scirrhus of the pylorus, and aneurism of the aorta, with this 
disease disseminated through the substance of the liver. Here is 
another preparation of what would be called by many persons pure 
! cancer; the patient, a female, had cancer of the mamma. This, 
j and the preparation on the other side, exhibiting a mass of white, 
! firm, semi-cartilaginous substances, are examples of what has been 
! called tubercle of the liver. Here is an example of the disease 
which has been termed whiskey liver, a disease which is said to be 
ordinarily found in persons who indulge in the use of ardent spirits. 
This, however, is a term which has been often abused and misap- 
plied; for persons indulging in the use of whiskey may have every 

18* 



202 



STOKES'S THEORY AND PRACTICE. 



form of disease of the liver, and the appearance before you may be 
detected in the livers of persons of the most temperate habits. On 
the label of this preparation is written — " A Specimen of Whiskey 
Liver," but this you will not mind. There is a very remarkable 
fact, however, respecting this kind of liver, verified by Professor 
Cars well, namely, that this condition of the liver is always accom- 
panied with more or less ascites. I may add, that I have never 
met with this disease without ascites. 

I remember a most remarkable case of disease of the liver, which 
occurred during my stay in Edinburgh. My lamented friend and ', 
instructor, the late Dr. William Cullen, whose loss to pathological 
medicine was irreparable, and whose splendid attainments and high 
character justly and rapidly raised him to an elevated rank in his 
profession, brought me to see a patient. One of the most curious 
circumstances connected with this case was, that when the patient 
sat up in bed, a fluid of a serous character was poured out in con- 
siderable quantity from the anus; but while he remained in the 
horizontal posture this did not occur. The patient died shortly 
afterwards ; and, on dissection, it was found that he had a gan- 
grenous abscess of the right lung, communicating with the pleural 
cavity, which contained a quantity of a sero-purulent fluid, and a 
mass of hydatids, some broken down, others perfect and entire. On 
continuing the dissection, it was found that the cavity of the pleura 
communicated with the right lobe of the liver through the diaphragm. 
In the right lobe of the liver the same kind of sero-purulent fluid, 
and a quantity of hydatids, were discovered ; and, what was still 
more extraordinary, the cavity in the liver was found to communi- 
cate with the colon by a distinct opening. There was, then, in 
this very remarkable case, a direct communication between the 
bronchial tubes and the colon, through the pleura and liver. We 
can thus see that, when the patient assumed the erect position, the 
fluid would immediately pour into the colon. 

As I am anxious to finish the subject of hepatic disease to-day, I I 
shall now draw your attention to one of the last points connected 
with this subject, namely — neuralgia of the liver. It is a singular j 
fact that a patient may labour under severe and harassing pain in 
the region of the liver; that this pain may last for months and 
years ; that he may die of some other affection ; and that, on 
examination after death, we may find the liver without the slightest 
trace of disorganization ; and, also, that the organs in its vicinity 
present no appearance of any organic disease. Many cases of this 
kind have been observed ; and it is the opinion of the best patholo- 
gists that they are examples of neuralgia, the seat of pain being the 
hepatic plexus. It is a disease of no very unusual occurrence, and 
is often found in females of a nervous and hysteric habit. It is 
constantly mistaken for hepatitis, and there is no greater mistake 
than this, or one which is likely to entail more misery on the 
patient. The persons who are subject to this affection are, as I 
remarked before, generally of a nervous and hysteric habit ; they 



TREATMENT OF CHRONIC HEPATITIS. 



203 



complain of pain in the right side, of more or less constant occur- 
rence, and this pain, during its exacerbations, is often most excru- 
ciating. Now, this circumstance furnishes us with a sort of key to 
diagnosis ; for with this dreadful pain, and, in some cases, exquisite 
tenderness in the region of the liver, we have the skin cool, the 
pulse tranquil, no fever, no permanent derangement of the bowels, 
no tumefaction of the liver. If this were the pain of acute inflam- 
I matory disease, a fatal result would be produced ; or if it belonged 
' to a chronic affection, it would terminate in organic derangement; 
and yet we find it existing with a clear colour of the skin and eye, 
healthy fasces, calm pulse, and absence of swelling in the region of 
the liver. Add to this, that the disease may have lasted for a con- 
siderable time, and that it occurs in a person of hysteric and 
nervous habit. Moreover, if the patient has been treated for hepa- 
titis unsuccessfully, you may make up your mind to the diagnosis 
of hepatic neuralgia. Here is the diagnosis ; pain in the region of 
the liver, with occasional violent exacerbations, and accompanied 
by tenderness of the integuments, but without swelling, symptoms 
I of fever, or abdominal derangement ; the disease being of long 
standing in a person of nervous habit, and having resisted bleeding, 
mercury, and even counter-irritation, or being made worse by those 
measures. 

Now, it is no uncommon thing to see this disease mistaken for 
acute hepatitis ; and I need not tell you how ruinous to the patient's 
health such an error must be. When you are in practice, you will 
meet instances of females labouring under this affection, who have 
gone through a variety of treatment. When you recollect that the 
disease occurs generally in hysteric females, and that such persons 
are injured by depletion, you can conceive how much mischief 
may be done by repeated bleedings and courses of mercury. Some 
of the most deplorable cases I have witnessed, were those in which 
neuralgia of the liver had been mistaken for hepatic inflammation, 
by a number of practitioners, and the patient subjected to such 
modes of treatment as gave her constitution a shock from which it 
j never recovered.* 

The treatment of this disease must be both general and local, but 

* [The pain being limited to one side, and its being increased by pressure, may 
strengthen the suspicion of the liver being the organ affected ; but we shall generally 
discover, with a little care, that the tenderness is more muscular and cutaneous than 
hepatic — the patient often shrinking from the first application of the physician's 
hand to the side. We can also commonly trace the pain and tenderness from one \ 
or two of the vertebra over the muscles on to the hypochondriac region, but 
! more above the margin of the ribs and external to them than below and inwardly. 
\ The practice which I find most useful in this variety of simulated hepatitis, or hepa- 
, talgia, is to apply about twenty or thirty leeches near the affected vertebra?, and 
! afterwards to induce counter-irritation by a small blister, or the tartar emetic oint- 
] inent or croton oil ; to act on the bowels by the blue mass and aloes, and then adminis- 
I ter five grains of sulphate of quinine daily for a week or a fortnight as the symp- 
toms, and the occurrence of damp and rainy weather, may seem to require, 
s Afterwards, if the neuralgic symptoms return, the sub-carbonate of iron should be 
I given, as directed in the text. — B.J 



I 



204 



STOKES'S THEORY AND PRACTICE. 



by no means what you would call antiphlogistic. You will have 
some difficulty in preventing the patient from getting herself blooded ; 
for though the lancet is inadmissible, yet its employment gives a 
temporary relief, and this encourages the patient to have recourse 
to it again. What I would advise you to do in this disease is, first 
to pay attention to the general condition of the patient. You must 
pursue a general anti-hysterical plan of treatment, remove every 
source of irritation and excitement, and take measures to improve 
the general health by exercise, regimen, moral improvement, and 
the judicious employment of tonic medicines. With respect to the 
pain, one of the most powerful means of arresting and removing it, 
appears to be the use of the carbonate of iron in full doses; and 
this is an interesting circumstance, when we recollect the power 
which it possesses in removing pain in other nervous diseases. 1 
would advise you to try this after having premised the use of pur- 
gatives, and continue it for some time, for you will often find that 
it will not only cure the pain, but also improve your patient's 
strength and appetite. While you are giving it, order your patient 
to take some mild purgative, as compound rhubarb pill, to prevent 
constipation. When you are about to prescribe a course of car- 
bonate of iron, you should prepare your patient to find the stools 
coloured. I have known this circumstance taken hold of and 
turned to their own advantage by quacks. The patient is told that 
his complaints arise from the existence of morbid and dark-coloured 
matters in his bowels. Preparations of iron are given, and the 
black matter begins to come away, greatly to the credit of the 
empiric. After a time, the medicine is omitted, and some purga- 
tive substituted ; the stools become natural, and the trick is com- 
plete. During the paroxysms of pain, a mustard plaster, or anodyne 
stupes, and anodyne enemata, will give relief ; and, in the intervals, I 
would advise you to use the belladonna plaster, after the following 
formula : — Take of extract of belladonna three parts, of gum am- 
moniac and soap plaster each one part; spread these on a piece 
of leather with an adhesive margin, and make the patient wear it 
over the region of the liver. If there be any tenderness over the 
lower dorsal vertebrae, you may apply a few leeches, followed by 
narcotic stupes, or counter-irritation. \ 
I have seen this hepatic neuralgia without any hysteric compli- < 
cation. I remember the case of a lady who had three or four 
healthy children, and had never been subject to hysteria. This 
lady came up to Dublin to be treated for liver disease — in fact, to 
be salivated ; but happening to fall into the hands of a judicious 
friend of mine, w T ho recognised the true nature of her complaint, 
she was treated with carbonate of iron, and cured effectually. I 
knew another case of a young gentleman, in whom (after being 
treated for symptoms of chronic hepatitis) this pain continued for a 
considerable time, and was at length removed by carbonate of iron, 
and the use of the belladonna plaster. i 



INTESTINAL WORMS. 



205 



LECTURE XIX. 

Gastritis, with delirium tremens — Varieties of intestinal worms — Organization and 
origin of — Occurrence in the foetuses of various animals — Formation — Pathology of 
— Perforation of the intestines by — Worms in tumours and abscesses. 

You may recollect that, when treating of acute gastritis, I alluded 
to the great importance of being aware of its complication with 
delirium tremens ; and stated, that in the form of delirium tremens, 
which is the result of an excessive debauch, and where the stomach 
has been subjected to powerful stimulation, we have reason to 
believe that there is more or less of gastric inflammation. 1 have 
it in my power, to day, to exhibit to you a very accurate drawing 
of the stomach of a patient who laboured under this form of disease, 
and whom I had an opportunity of examining several times before 
death. You will remember, also, I mentioned that in cases where 
, symptoms of delirium tremens had arisen from excess ; and not from 
I a want of the customary stimulus, the ordinary routine treatment 
of giving wine, brandy, and other spirits, was extremely improper 5 
and that where it was persevered in, and the patient died, you com- 
monly found, on dissection, evident marks of inflammation in the 
brain and stomach. On that occasion, too, I quoted this as an 
I example of the latency of gastric symptoms when complicated with 
I an affection of the nervous centre. I have now to exhibit this 
drawing, which represents the stomach of a man who died of deli- 
rium tremens, supervening on a severe debauch. This patient was 
treated entirely on the stimulant plan ; he got wine, porter, brandy, 
and opium, but their exhibition was not attended with the slightest 
benefit. Under their use his symptoms changed, and assumed a 
decided cerebral character ; he had hot skin, quick pulse, great 
thirst, and general symptoms of fever, accompanied by a comatose 
condition. Previously to opening the body, I gave it as my opinion 
that the stomach would be found to exhibit marks of inflammation. 
Here is an accurate drawing of the stomach, and, from its appear- 
ance, you will be able to judge for yourselves. (Here Dr. Stokes 
exhibited the drawing to the class, representing the stomach in a 
state of intense vascularity.) Observe the generally diffused dark 
red colour of the whole organ, and the excess of inflammation 
towards its cardiac orifice. The brain, in this case, was but slightly 
vascular. 

I propose to devote this day's lecture to the consideration of an 
I interesting subject in practical medicine — intestinal worms. There 
are few subjects possessing so much interest, in a physiological and 
! pathological point of view, as this ; and, in order to have correct 
I notions, it will be necessary for you to be acquainted with the 
i investigations of modern science on this subject. You are well 
I aware that worms are found in most classes of animals. They, 
I occur in reptiles, fishes, birds, in the different classes of quadrupeds, 



20G STOKES'S THEORY AND PRACTICE. 

f 

and in man. In man they do not exist in such abundance, nor so 
frequently, as they do in birds and fishes. With respect to their 
places of habitation, we find them, first, in cavities which have an 
external communication, and next, in the parenchymatous sub- 
stance of organs ; and we generally observe, that those which 
inhabit the cavities are different from those met with in paren- 
chymatous parts. We observe, also, that the species existing in 
the different organs and cavities are not only different in their 
nature, but that there is a difference between the worms which 
inhabit separate portions of the same organ or cavity. In one part 
of a cavity or organ we find one species, in another a different, and 
this occurs almost invariably, as if it was regulated by a fixed law 
of the economy. A peculiar species of worm, occurring in man, 
called the distoma hepalicum, is never found except in the liver or 
gall-bladder. If this animal had been introduced from without, it 
would certainly be detected in some part of the intestinal canal, but 
this is never the case. Rudolphia states, that the strongylus 
horridiis is to be met with only in the oesophagus, of aquatic birds, 
and the ascaris obtusa in the stomach of mice. 

Generally speaking, worms are of three different forms — cylin- 
drical, riband-shaped, and vesicular. Their organization varies 
from the lowest scale, in which we can scarcely trace, as it were, 
the rudiments of an animal ; beginning with the tape-worm, which 
presents little more than a cellulo-gelatinous mass, we ascend 
gradually until we arrive at a high degree of organization, where 
we find well-developed muscles, a difference of sex, generative 
organs, and, according to some anatomists, a tolerably perfect 
nervous system. 

Now, to remove all sources of doubt and error on this interesting 
subject, and to establish proper principles of treatment, let us 
examine into the origin of these animals. I shall confine myself to 
the consideration of the origin of those worms which inhabit the 
human intestines, as they are the only species which we have to do 
with as practical physicians. 

You will at once perceive that worms must be derived from one 
of two sources ; either as introduced from without, or formed 
originally within the bodies of man and other animals. It is main- 
tained by those who are in favour of the first supposition, namely, 
that they are introduced from without, that similar animals are to 
be found in the external world, and that they are introduced either 
in the form of ova, or in a state of perfect development, with the 
food or drink, or by the respiration of the animal. Observe, this 
doctrine is founded on the validity of the assertion as to whether 
animals similar to intestinal worms are to be met with in external 
nature. Linnaeus states, that he found the tape- worm, and the 
small ascarides, a species now called oxyuris vermicularis in a 
marsh in Lapland ; but Muller, a much more accurate helmintho- 
logist, has since shown, most satisfactorily, that Linnseus was com- 
pletely mistaken, and that those he had observed are never found 



INTESTINAL WORMS. 



207 



to exist within any animal whatever. There are many observa- 
! tions on record similar to those of Linnaeus ; but as they were 
j made at a time when natural history was in its infancy, and as they 
I have been disproved by the researches of modern zoologists, I shall 
j not notice them. I believe there is no well-authenticated instance 
j on record of tape-worms, lumbrici, or ascarides, being found living 
j in any situation external to the animal body. Every one of you 
j have seen worms in the intestinal canal, or recently discharged by 
1 stool or vomiting ; but I will venture to say that not one has ever 
| observed them in any article of food, in earth, or in water. 
I Bremser, who is a high authority, makes a very pertinent remark 
on this subject. " We find," says he, " all animals most abundant 
| in that situation which has been assigned to them by nature. Now, 
I if these animals were accidently introduced from without, we 
| ought to find them more abundant in the earth, water, &c. ; but 
j the contrary we have seen to be the fact." 

But it is contended that these animals may have been introduced 
from without, and that in consequence of a change in situation, 
| nutriment, and other circumstances, their forms may be altered ; 
I and it is argued, in support of this hypothesis, that external cir- 
cumstances will and have been observed to change the forms of 
; plants and animals in a very remarkable degree. In addition to 
this, it may be said that an alteration in the nature of its food may 
even produce an actual change in the function of the animal. It 
is a singular fact that neuter bees may be made prolific by chang- 
I ing their food ; it is shown that when a queen bee dies or is lost, 
the neuter bees take a grub of their own species in place of her, 
I and, by feeding it in a particular manner, it becomes capable of 
laying eggs. 

Now, supposing that intestinal worms are introduced in the form 
of ova into the human body, there is no reason why this sudden, 
remarkable, and complete change should take place. We see 
nothing similar to it in nature. The plant which springs from 
any particular seed will resemble that from which it derives its 
origin ; the egg of any particular bird, no matter in what way it 
may be hatched, will produce an organized being similar to its 
parent. The form and character of the animal are given during 
! the act of generation, and remain unchanged. Again, admitting 
that a difference in circumstances and nutrition might produce a 
total change in form, it should be in our power to demonstrate the 
individual in the process of transition ; we should find those animals 
in a state half between what they were and what they are, and this 
| state we should observe of very frequent occurrence. No such 
j thing, however, has been ever demonstrated. Out of a vast 
; number, Bremser did not find a single one in any stage of tran- 
| sition, nor has it been demonstrated by any zoologist. He also 
j states expressly, that after having diligently examined fifteen thou- 
I sand specimens of worms in the cabinet at Vienna, he never was 
j for one moment at a loss to say which were intestinal worms and 



i 



STOKES'S THEORY AND PRACTICE. 



which were not. If there was any such transition, it would have 
been discovered, but no such thing has ever been observed. 

It appears, then, obvious that there is no direct evidence to prove 
that these animals have been introduced into the body from with- 
out, either in the form of ova, or in a state of perfect development, i 
We have nothing, then, I think, but to come to the other conclu- 
sion, that they originate within the body, and this seems to be the 
opinion of the best physiologists and pathologists. This doctrine 
appears to be almost brought to a demonstration by the following 
facts. First, it appears that the worms which have been found in 
man and animals have a peculiar structure and organization, differ- 
ing materially from that of the worms which inhabit the external 
world. This is a point admitted by almost every modern writer 
on natural history. In the next place, we find that the worms of 
certain animals present peculiarities differing from those of the same 
species in others. Thus the bothricephalus and toenia solium, in 
man, differ from those of other animals. You are not, however, to 
conclude from this that every animal has its peculiar worms, for 
such is not the case. Thus the lumbricus and small ascarides of 
man are found to exist in various animals, both carnivorous and 
graminivorous. 

It appears obvious, that if worms were introduced from without, 
we should not find peculiar worms in the bodies of certain animals ; 
yet taking a certain number of different animals, living on the same 
food and in the same situation, we find a difference in the nature of 
the worms which are met with in the bodies of each. Another 
important fact is, that worms are to be found not only in the intes- 
tinal canal, but in almost every part of the body. We find them in 
the celiular tissue, in the liver, gall-bladder, lungs, and trachea ; 
in the brain, heart, kidneys, and spleen. They have been met 
with in the air-bladders of fishes ; and Treutter states that he has 
found the polystoma pinguicola in the ovaries of a woman which 
were steatomatous, and the strongylus in an aneurism of the mesen- 
teric artery of the horse. These animals have been observed in 
the anterior chamber of the eye in birds and horses, and there are 
innumerable examples of their occurrence in situalions equally 
strange and anomalous. Another circumstance already mentioned, 
and which must be coupled with the fact just alluded to, is that 
there are certain species of worms which occur only in the same 
organs, and are never met with in any other situation. 

Now, observe the importance of these facts — we find that worms 
not only exist in the digestive tube, and parts having an external 
communication, but also in the very substance of deep-seated 
viscera, and that the worms which are found in the various cavities 
and organs are peculiar to them. In one case, we find a worm in 
the digestive tube, in another in the brain, in a third in the liver, in 
a fourth in the pulmonary apparatus, but no one has ever been able 
to demonstrate the trajet of a worm from one of these cavities or 
organs to another. It would be ideal and absurd to say, in the case 



INTESTINAL WORMS. 



209 



of worms found in the substance of viscera, that they had been 
introduced from without, or came from the intestinal canal. The 
distoma hepaticus, which is found in the liver and gall-bladder, 
might be supposed to arrive at those situations by passing along 
the ductus communis choledochus ; but in the various cases in 
which it has been found, it has never been detected in the intestinal 
canal ; and this, I think, would not have been the case, if the 
! digestive tube had been its original situation. One of the most 
important facts which have bee'n stated is, that certain forms of 
these animals are found invariably in certain situations ; and this 
has been observed not only in man, and other animals of the class 
j mammalia, but also in reptiles and fishes. In man, we generally 
find the lumbricus inhabiting the stomach and small intestine, the 
tricocephalus in the csecum, and the small oxyuris, or thread-worm, 
in the rectum. The preparation before me exhibits a specimen of 
the rarest form of worms which inhabit the intestinal canal, the 
tricocephalus. Here is the csecum filled with these singular worms, 
j The males are distinguished from the females by the whirl of the 
tail. If these little animals, or the oxyuris, had been introduced 
from without, we should expect to find them in various parts of 
the intestinal canal ; but we find, on the contrary, that their situa- 
tion is separate and distinct. 

Lastly, intestinal worms have been found in the foetus both of 
man and other animals. Kerkring describes a foetus, the intes- 
tinal canal of which contained a vast quantity of small worms ; and 
another of six months, in whose stomach a large lumbricus was 
found. Rudolphi, Biumenbach, and others of nearly equal autho- 
rity, have recorded abundance of examples of worms existing in the 
foetuses of various quadrupeds, and also in those of birds which 
had just broken the shell. Those who are obstinately attached to 
the doctrine that worms are introduced from without, have gone so 
far as to assert, that the ova of the worms have been transmitted at 
the moment of generation, a doctrine so absurd that it is unneces- 
sary for me to enter into any refutation of .it. 

With respect, then, to the formation of worms in animals, we 
cannot help coming to the conclusion that they are originally 
formed within the body, and that, in fact, there is an original gene- 
ration of these animals, the result of one organization taking place 
within another — the production, in fact, of a distinct being. This 
idea does not appear so difficult of conception when you recollect 
that circumstances analogous to it are extremely familiar and of 
almost constant occurrence. There is not much more difficulty in 
conceiving the formation of a living worm within the body than 
i there is of conceiving the organization of a portion of lymph thrown 
out upon the surface of a serous membrane. What occurs in both 
cases is, that, under the influence of the vital principle of the original 
animal, a portion of matter, previously inorganic, assumes the pro- 
perties of life, presents distinct traces of organization, vascularity, 
and sensibility. The only difference between them is, that in one 

19 



210 



STOKES'S THEORY AND PRACTICE. 



case the organized mass remains adherent to the matrix, and in the 
other it is cast off, and forms a separate being. In the present 
state of our knowledge, all speculation on the mechanism of the 
formation of worms must of necessity be nothing more than mere 
hypothesis. The idea which Bremser entertained on this subject 
is, that intestinal worms are formed by the presence of semi-assimi- 
lated nutritious matter in the digestive tube. Food, taken into the 
system under ordinary circumstances, is converted into a substance 
fitted for the purposes of absorption and nutrition; but when the 
process is not perfected, it is not taken up by the absorbents, and is 
then, according to Bremser, converted into an animal substance. 
This appears to be but a crude idea, unsupported by any facts ; and 
it would be more philosophical to say that we know nothing about 
the matter. Besides, worms occur in various parts of the body as 
well as the digestive tube ; and to suppose the presence of unassimi- 
lated matter in such situations would be only supposing an absurdity. 
Bremser brings forward, in support of his theory, that worms are 
of very frequent occurrence in cases where the assimilating powers 
are weak or deranged, and says that nothing is more common 
than to meet with an abundance of these animals in scrofulous per- 
sons, in those who have great appetites and bad digestion, and in 
children labouring under disease of the mesenteric glands. On the 
other hand, there are abundant instances of worms existing without 
the slightest apparent injury to the general health. In certain 
countries almost all the inhabitants have worms. But I believe all 
that we can affirm on this subject is this, that they are not intro- 
duced from without, and that they are formed within the body by 
a process, the nature of which is exceedingly obscure. 

Now, to come to the pathology of this subject, can we connect 
the formation of intestinal worms with any known pathological 
condition of the intestinal canal? This is a question of no ordinary 
importance; for if we were able to connect their formation with an 
inflammatory or any other state of the digestive tube, it would 
furnish us with a key to correct and successful treatment. The 
school of Broussais are of opinion that worms are the result of an 
acute or chronic inflammation of the gastro-intestinal surface. 
This doctrine is by no means supported by the evidence of facts, 
for it has been established that worms are found to exist not only 
in connection with every possible pathological condition of the intes- 
tinal canal, but also where the tube presented the appearance of per- 
fect health. We cannot, then, safely affirm that intestinal worms 
are connected with an inflammatory or non-inflammatory condition 
of the digestive tube. Andral states that he has found them in all 
conditions of the intestine, whether red or pale, dry or covered 
with mucus. They are most commonly, he says, enveloped in a 
quantity of mucus, and there is some redness in the place where 
they are lodged ; but this appears to be rather the effect of their 
presence than the cause. I believe it to be the fact, that persons in 
excellent health, and with the intestinal canal in the normal state. 



INTESTINAL WORMS. 



211 



may have worms. Dogs, who are killed while in a siate of ap- 
parently perfect health, are often found to have a large quantity of 
tape-worm in their intestines. It is idle and hypothetic to say, that 
the formation of worms depends upon an inflammatory or non- 
inflammatory, an asthenic or sthenic condition of the digestive 
tube ; their formation is owing to some modification of the vital 
power, the nature of which is unknown. I again repeat, that 
! nothing can be stronger against the supposition that worms depend 
upon inflammation than the fact of their being observed in consi- 
j derable quantities in healthy individuals. 

A very curious point, connected with this subject, is the question 
I of perforation of the intestines by worms. This question, which is 
an interesting one in many points of view, has been lately the sub- 
| ject of medico-legal discussion, and therefore demands a share of 
our attention. Of the different kinds of intestinal worms, the only 
one which is supposed to be capable of perforating the coats of the 
digestive tube, and escaping into the peritoneum, or some adjoining 
organ, is the lumbricus, which is remarkable for its vigour, and for 
the sharp and pointed shape of its head and tail. Many of the 
most eminent pathologists of modern times, and, among the rest, 
Andral, Rudolphi, and Carswell, are of opinion that these worms 
are totally incapable of perforating the intestinal tunics. Andral 
states that there is no well-authenticated instance of this occurrence 
on record; and Rudolphi declares that they have no apparatus for 
! effecting a passage through any continuous tissue. On the other 
side of the question, however, there are some curious facts and 
cases given, which, supposing that worms are incapable of perfo- 
rating, are very difficult to explain. Dr. Fischer, of Vienna, gives 
the case of a female, in whom the following circumstances were 
observed on dissection. Two circular orifices were found in the 
colon, communicating with the cavity of the peritoneum; in one of 
these openings a worm was discovered, one half of which lay in 
the peritoneal sac, the other in the intestine. No other worms 
were found in the digestive tube ; but a second worm, like the 
former, w T as found in the peritoneum. Here w 7 e have a very 
remarkable coincidence of perforation of a portion of the gut, w 7 ith 
the existence of one worm in the cavity of the peritoneum, and 
another of a similar description, as it would appear, in the act of 
I making its way in the same direction. These circumstances, 
together with the existence of a double perforation, seem to be in 
I favour of the idea that the openings had been made by the corres- 
ponding worms. Another case is mentioned in the Elements of 
Pathological Anatomy, by Andral, and he quotes the case, not as 
one of perforation merely, but to show that the symptoms of effu- 
sion of matter into the peritoneum may, under certain circum- 
stances, be nearly latent. The subject of this case, a young man, 
labouring under phthisis, had a tumour near the umbilicus, which 
increased rapidly in size and presented a distinct fluctuation. 
Soon afterwards, the integuments gave way, and a large quantity 



212 STOKES'S THEORY AND PRACTICE. 



of matter was discharged, together with a lumbricus. During the I 
progress of this disease, there was some tympanitis, but little or no 
pain had been complained of. On dissection, there was a consider- 
able number of worms, and a quantity of matter, found in the peri- , 
toneum, and a perforation in the arch of the colon, corresponding 
with the extravasated matter. Bremser gives a curious instance of 
this kind, as occurring in a species of fish. In this case, the fish 
died ; and it would appear, says Bremser, that the worm, finding 
some extraordinary change had taken place, was determined to take 
a peep and see what was the matter, for it had perforated not only 
the intestinal tube, but actually made a passage for itself through 
the whole body of the fish, until it reached the water in which it 
had been lying. Here, finding that its world extended no further, i 
it stopped, and began to make its way back again to its original 
situation by a new opening, so that when, it was observed by 
Bremser, the two ends were in the intestinal tube of the fish, and 
the middle portion external. This, however, does not resolve the 
question, as to whether lumbrici are capable of perforating the 
intestinal canal or not. My own impression on the subject is, that 
we have not, as yet, any distinct and unquestionable evidence of 
these worms being possessed of any perforating power ; but it is a 
fact, that there are a great many cases on record of worms being 
discharged in considerable quantities from openings in the intestinal 
tube, and where it would appear that the openings had been formed, 
not so much by the action of the worms themselves, as in conse- 
quence of their exciting an irritation in some portion of the intestine, 
followed by inflammation, ulceration, and escape of the contents of 
the tube into the peritoneum. There are many instances of this 
kind. An interesting case is mentioned of a female, who was at- | 
tacked with pain in the groin, followed by the appearance of a 
tumour, which she was directed to poultice by her medical attendant. 
After some time, the integuments gave way, a quantity of matter 
was discharged, followed by a large lumbricus, and during the j 
progress of the case about one hundred of these; animals were dis- 
charged through the opening. This is a well-authenticated case, j 
Another case is mentioned of a patient who had been subject to 
constipation and violent attacks of colic. A tumour began to appear 
in the right hypochondrium, followed by pointing and ulceration of 
the integuments, and a discharge of matter. A number of worms 
(I believe twenty-four) were discharged through the opening, which 
remained pervious, and the patient, lived for many years afterwards 
with an artificial anus. This case appears to be not an example of 
direct perforation from worms, but of the accumulation of a mass 
of these animals in a particular portion of the intestine, giving rise 
to irritation, which terminates in ulcerative absorption of its tunics, 
and escape of its contents. Inflammation is set up in some part of 
the intestine, this goes on until the coats are all destroyed, and the 
matter and worms escape into the peritoneal cavity ; but if adhesion 
should prevent this, an opening will be formed in some part of the 



INTESTINAL WORMS. 



213 



i integuments covering the belly. In both cases, the opening is pro- 
duced not by an exertion of the worms, but by an ulcerative and 
I vital process. In support of this view, it has been observed that 
| worms have come out through these apertures not head foremost; 
I the centre portion appears first, and you can draw it out like a 
I loop. Such cases as the foregoing, then, cannot be fairly given 
I as cases of perforation from worms, but as cases in which these 
animals, acting somewhat like foreign bodies, produced irritation, 
\ inflammation, and ulcerative absorption. There is a very curious 
| case on record, of a patient labouring under abscess of the liver, 
which burst externally, and a lumbricus was discharged with the 
j matter. The patient died ; and, on dissection, it was found that 
the cavity of the abscess had a communication with the stomach, 
| through which it was conceived that the lumbricus had got into 
| the liver. 

The worms which inhabit the intestinal canal in man are the 
following: — first, the lumbricus, or common round worm; next, 

| we have the tape-worm, of which two varieties have been described ; 

i thirdly, we have the very curious worm, of which there is a speci- 
men before me — it inhabits the caecum, and is called tricocephalus ; 
lastly, we have the thread-worm, to which the name of oxyuris 
yermicularis has been lately given. The lumbricus generally 
inhabits some portion of the small intestine, but is also frequently 
found in the stomach. Persons have often vomited them, and they 

j have been known to have crept out by the mouth. They have 
been found also in the pharynx, oesophagus, and large intestine. 
There is an interesting case mentioned by Andral, of a child who, 
in a state of apparently good health, was suddenly seized with 
symptoms of suffocation, and died. On dissection, it was found 
that a large lumbricus, which had come up from the stomach, had 
when it arrived at the glottis, turned into its orifice, and, by irritat- 
ing the larynx, produced spasmodic closure of that organ, and suf- 
focation. 

The lumbricus presents very marked appearances of an advanced 

state of development. The male has a peculiarly formed penis ; 
j the female has her generative organs well developed; and both 
! have an extensive alimentary canal. The tricocephalus is about 
j an inch in length, terminating in a point ; the sexes are different, 

and the male is distinguished from the female by the circular whirl 
i of his tail— it is always found in the caecum. The small thread- 
j worms, with which you are all acquainted, are almost exclusively 
j found in the rectum. These worms are found in vast numbers in 
j some children ; and it is said that the quantities of them which are 

discharged by the West Indian negroes are extraordinary. 

The tenia, or tape-worm, is generally found in the small intes- 
I tine ; but it has also been observed in the stomach, colon, and 

rectum. The length to which this animal sometimes attains is 
I almost incredible. Bremser mentions a case in which a tape-worm 

one hundred and fifty feet in length was discharged bv stool. 

19* 



I 



214 



STOKES'S THEORY AND PRACTICE. 



Another case is given, in which the tenia had the enormous length 
of three hundred feet. I have myself seen a large wash-hand basin 
filled by a mass of tape-worm, discharged after a strong dose of 
castor oil and turpentine. Still more extraordinary instances are 
recorded. Thus, in the Copenhagen Transactions, we read of a 
tape-worm eight hundred ells in length. But, in all probability, 
there has been an error in these measurements, and many worms 
have been taken for one. This is rendered probable by the fact 
observed by Robinus, who found in the body of a man, who had 
before death discharged fragments of tape-worm, a tape- worm 
extending from the pylorus to within six inches of the anus. The 
length of this single worm was scarcely thirty feet. One interesting 
circumstance connected with this animal is, that it is inferior in its 
organization to every other species of worm. It appears to be 
nearly a simple, homogeneous, cellulo-gelatinous mass, without 
any division of sexes, and without a nervous system, or generative 
organs. It is said, also, to occur principally in persons whose 
powers of life are low ; and if this be the case, as I believe it is in 
many instances, it furnishes us with a very curious and interesting 
fact. The other better developed kinds are found in persons of 
healthy, good constitutions ; but the tape-worms, though sometimes 
met with in such persons, are generally found to occur in persons 
of low and weak diathesis. Here we see a curious connection 
between the product and the producing cause. 

With respect to the exciting causes of worms, a vast number of 
circumstances have been mentioned by authors, as giving rise to 
their formation. Foul air, low, damp situations, bad diet, the con- 
stant use of milk, cheese, sugar, vegetables, have been reckoned 
among their exciting causes. I believe we are not well acquainted 
with these causes. They appear often to be connected with some 
morbid influence produced upon the system by bad diet, and other 
circumstances; but what the nature of this influence is, we know 
not. 



LECTURE XX. 

Symptoms of intestinal worms — Sympathetic irritations — Affections of the nervous 
and respiratory systems — Various diseases mistaken for worms — Exciting causes of 
worms — Farinaceous and milk diet — Verminous fever — Treatment of worms — Speci- 
fic and mechanicaFpurgatives ; calomel, turpentine, &c, &c. — Remedies for each 
species of worms — Preventive measures. 

Let us proceed with the consideration of intestinal worms. At 
my last lecture you will recollect that 1 spoke of the different kinds 
of worms, and stated that there was a difference between the worms 
which are found in various parts of the body; that I examined the 
question as to the origin of these animals, and came to the conclu- 
sion that they are formed originally within the bodies of man and 
other animals. I mentioned the various kinds of worms which 



SYMPTOMS OF INTESTINAL WORMS. 215 

| inhabit the digestive tube in man, and examined at some length the 
question of perforation of the intestinal canal by lumbrici. We 
come now to the investigation of the symptoms. 

With respect to the symptoms of worms, it is a singular fact, 
that we have not one single pathognomic sign of their existence, 
except the circumstance of their being occasionally passed by 
stool, or vomited; almost all their symptoms are referable to irrita- 

! tion of the gastro-intestinal surface, and its sympathetic relations. 
Persons, who are much subject to worms in these countries, are 
generally of a pale complexion, with a bluish circle round the eyes ; 
the belly is more or less prominent, and there are various signs of 

j irritation of the digestive tube, with itching at the nose and anus ; 
headache; foul breath and tongue ; irregular and sometimes canine 

| appetite, nausea, hiccup, borborygmi, tenesmus, diarrhoea, and 
constipation. Though the patients take abundance of nutriment, 
they are generally thin and pale; and in such cases there is either 
one or two very large worms, or a great number of smaller ones, 
or their presence is complicated with disease of the intestinal canal. 
Such persons are also observed to be of an indolent and languid 
habit ; they have perspirations, disturbed sleep, with grinding of the 
teeth, and irregularity of pulse. 

The sympathetic irritations produced by worms are numerous 
and extraordinary. The genital organs may be excited, and we 
may have priapism and seminal emissions in the male, and irrita- 
tion amounting to nymphomania in the female. There is a very 
singular case on record of a female, aged seventy, being seized 
with a violent attack of nymphomania from this cause. The 
nervous affections produced by worms are so Protean and so 
numerous, that it would be almost impossible to detail them; in 
fact, there is not a single nervous disorder which may not be simu- 
lated by the sympathetic irritation of worms. Epilepsy, hysteria, 
convulsions, dilatation of the pupil, amaurosis, symptoms of hydro- 
cephalus, and even mania, are among the affections of the nervous 
centres or their immediate connections, which, in repeated instances, 
have been found to depend on the presence of worms. Kraus 
gives an extraordinary case of a man, who, at* a very advanced 
age, became subject from this cause to fits of continued and inor- 
dinate laughter. 

There is another case on record of convulsions depending on 

worms, which, like those from the bite of the tarantula, are said 
| to have been soothed and relieved by music. Hufeland, in his 
i journal, mentions a case of yellow vision from the same cause ; 

and there are several instances of aphonia and mania on record, 
! which have yielded to treatment which had removed intestinal 
i worms. A case is mentioned of a person who got violent spasmo- 
j die action of the muscles of the eye, producing inversion of that 

organ to such a degree that the eyeball appeared to be nothing 
! more than a mass of red flesh. A case is recorded by Serres, in 

which the symptoms strongly resemble those of hydrophobia ; and 



216 STOKES'S THEORY AND PRACTICE. 

it is probable that some of the cases of hydrophobia, said to have 
been treated successfully, were nothing more than this extraordi- 
nary irritation of the nervous system produced by worms. I saw, 
myself, a case in which two eminent physicians made the diagnosis 
of hydrocephalus ; it was that of a child, who was certainly, to all 
appearance, labouring under cerebral disease — for he had convul- 
sions, coma, and dilated pupils. It was remarkable, however, in 
this case, that the treatment directed to the head, though early and 
well applied, proved totally inefficacious. A large dose of calomel 
was given, and some lumbrici passed ; in the space of two or three 
hours there was an evident improvement, and the child quickly 
recovered. 

During the course of practice I have met with several examples 
of affections of the respiratory organs, depending upon the irrita- t 
tion of worms. This affection has been long known. I recollect 
the case of a boy who was brought to me with an extraordinary 
affection of the chest. He was of a gross habit of body, of a flabby ) 
scrofulous appearance, and labouring under disease of the elbow- { 
joint ; but his chief complaint was, that he passed the night in t 
great distress from incessant cough and wheezing. On examining i 
the chest, I found the respiration healthy, and no other symptom 
of pulmonary derangement except a very slight bronchitic rale, ? 
On expressing my opinion of the case to the mother, she said that ] 
he was easy during the day, but that his condition was very differ- a 
ent at night. To ascertain the truth, I took the child into the J 
hospital, and found that her statement was substantially correct; a 
for, from four o'clock in the afternoon until next morning, he was ? 
in a state of perfect orthopnoea, with loud, ringing, incessant cough, p 
During the rest of the day he was free from cough, and tolerably |l 
quiet. The case was treated with calomel and ipecacuanha, tartar \ 
emetic, and other similar remedies, but the disease was rather ex- b 
asperated than improved. The boy had swelled belly and consti- |i 
pation, and for this he was ordered to take a dose of turpentine and It 
castor oil. He passed some worms with relief to the existing v 
symptoms ; and from the consideration of this, and the failure of jj 
the treatment for bronchitis, we were determined to persevere in b 
the use of anthelmintic medicines, and for this purpose put the \ 
child on syrup of cowhage, to be followed by castor oil draughts. ; 
He passed vast quantities of thread worms in the course of a few i 
days, and when they had been all removed the cough disappeared 
altogether; but, as long as any of them remained, the symptoms 
of pulmonary irritation continued. There could be no doubt that « 
this was a case of intermittent bronchial irritation from worms, for [ 
their evacuation was immediately followed by a complete cessation N 
of cough and dyspnoea. I have also, since the foregoing, met with 
many other instances of a similar description. A young girl came i 
into the Meath Hospital with chronic bronchitis, and some degree 
of hepatization at the lower part of the left lung. Having heard i 
from her friends that she was extremely subject to worms, I deter- | 



SYMPTOMS OF INTESTINAL WORMS. 



217 



mined to try what would result from the use of anthelmintic 
medicines, and put her on the syrup of cowhage with aloetic pills. 
Under this treatment the cough was quickly removed, and the 
lower portion of the lung recovered its permeability. Here it was 
remarkable, that not only irritation of the bronchial mucous mem- 
brane, but even solidification of the lung, were cured by treatment 
calculated to remove worms. Mr. Ramsay, in his paper published 
in the Medico-Chirurgical Transactions, gives several cases of 
haemoptysis from this cause. I think I have seen several cases of 
phthisis, where the original source of pulmonary irritation seemed 
to be the existence of intestinal worms. 

Let me here, however, remind you that we should be cautious 
in attributing too much to worms as the causes of morbid symp- 
toms. There are several reasons why you should be on your guard 
in this respect, one of the most obvious of which is this: it does 
not follow, in the first place, that the symptoms in any particular 
case are produced by worms; because the same cause, which may 
have predisposed to the formation of worms, may have produced 
the symptoms in question, and there may be merely a coincidence 
of worms and of these symptoms. Even if we look to the results 
of treatment, there is a great deal of doubt and difficulty. There 
are many cases on record which are described as cases of epilepsy 
from worms, and where all the symptoms have subsided under the 
use of anthelmintic medicines. In many of these cases we find 
the medicine chiefly employed has been oil of turpentine, and I 
need not tell you that this is an excellent remedy in many cases of 
epilepsy totally uncomplicated with worms. The results of such 
cases do not necessarily prove that worms were the source of irri- 
tation. Again, immense injury is frequently done to children in 
persisting in the anthelmintic treatment for the supposed existence 
of worms. Recollect, the prominent phenomena of worms in the 
intestines are irritations of the digestive system and of other func- 
tions. Now, it is very well known that these symptoms may occur 
with or without worms. If, then, you have a case where these 
phenomena are present without the co-existence of worms — and if, 
under a mistaken impression, you treat it with anthelmintic medi- 
cines — you inflict a double injury : you exasperate the original 
disease by the drastic and irritating medicines which are ordinarily 
used for the removal of worms, and you do an indirect injury by 
neglecting to adopt proper means of treatment. There is nothing 
more common than to see children labouring under some irritation 
of the digestive tube, which is mistaken for worms, purged again 
j and again, until they get incurable enteritis or tabes mesenterica. 

When a child has foul tongue and breath, picking of the nose, 
| diarrhosa, and turbid urine, it is a common notion that he is labour- 
ing under worms. If he gets feverish, it is said to be worm-fever, 
and the anthelmintic treatment is pursued with unabated vigour. 
Now, I believe that a great majority of such cases are, in reality, 
disease of the mucous surface of the intestine, and that the conse- 



218 



STOKES'S THEORY AND PRACTICE. 



quent feverishness is dependent on this state. Another reason why 
you should be cautious is this : in persons of an hypochondriac 
habit, there is nothing more injurious than their getting the idea 
that they have a worm in their bowels. When once this notion 
gets into the head of an hypochondriac, it is generally impossible 
to eradicate it. Some of the most melancholy and fixed cases of 
hypochondriacism are produced in this way; every symptom is 
attributed to the worm ; the patient is in a state of constant feverish 
anxiety about it; he talks of nothing else, and is constantly taking 
medicines to expel it, to the great detriment of his general health 
and with a manifest exacerbation of his symptoms. Medical men 
should be extremely cautious on this point. The patient is perhaps 
a female of hypochondriac and nervous habit ; she has gnawing 
sensations about the epigastrium, which she supposes to depend ■ 
upon the presence of a worm, and an injudicious practitioner 
favours the notion. He gives her various medicines to expel the ^ 
worm; no worm is passed; she becomes more anxious, takes more 
medicine, and gets weak and emaciated. She then begins to 
think that all the nutritious matter in her body is going to support 
the worm, falls into a desponding state, and continues for the rest 
of her life an incurable hypochondriac. 

We come now to consider the exciting causes of worms. On 
this subject I believe our knowledge is very scanty and inaccurate. 
The following, however, are generally looked upon as remote 
causes: — foul air, residence in damp and unhealthy situations, 
sedentary habits and want of wholesome exercise, over-feeding, 
the constant use of certain articles of diet — as farinaceous sub- 
stances, milk, cheese, sugar, &c. An eminent authority (Bremser) 
asserts, as I have already stated, that unabsorbed chyle in the 
digestive tube constitutes the most fertile source of worms. It is a 
common idea, that poor diet has a strong tendency to give rise to 
the formation of these animals, but it has been frequently observed ] 
that worms are met with in persons who are by no means in want;, 
of nourishment; and it is said, that, in cases where nutrition has 
been diminished in man and other animals, the worms die. If this;! 
be the case, it would appear that, so far from being the exciting 
causes of worms, poor diet rather tends to favour their removal. 
Uncooked vegetables and fruits are also reckoned among the 
causes of worms, but I believe this arises from the mistaken notion' 
that the ova of intestinal worms occur in vegetables, and, being 
taken with them into the stomach, are there developed, or even 
changed in their organization — a position which we have already 
proved to have no foundation in truth. Persons who live princi- ( 
pally on vegetable food have not been observed to labour under 
worms in a comparatively greater degree than those who use an 
animal diet. It is said that the Swiss, who consume a great deal 
of vegetables, are very subject to worms; but other nations, who 
live in a similar way, have not been remarkable for the same; 
liability. 



SYMPTOMS OF INTESTINAL WORMS. 219 

I Worms have been stated to be occasionally epidemic. It is not 
| very easy to determine this point, but it has been remarked that, at 
I particular periods, these animals have been more than usually fre- 
! quent and numerous. Many authors have described an epidemic 
I of what has been called verminous fever ; that is to say, fever of a 
gastric or bilious character accompanied by worms in quantity. 
! It is hard to say what the nature of this fever really was, and 
| whether it might or might not be fever with irritation of the diges- 
i tive apparatus, one of the consequences of which was a discharge 
I of worms already existing. That worms are endemic, is a propo- 
! sition very easily conceived ; for we see it illustrated by the extra- 
I ordinary prevalence of these animals in sheep which are kept in 
low, damp pastures. In such situations worms are met with in 
S great abundance in the liver and other parts of these animals. 

It would appear from the following remarkable case, detailed by 
! Bremser, that the use of milk and farinaceous food predisposes to 
1 the formation of intestinal worms. This gentleman, who was phy- 
j sician to a monastery, and had ample opportunity of studying the 
' habits of its inmates, was called to visit one of the oldest of the 
| monks, who was said to be labouring under great derangement of 
the digestive system. On inquiry, he found that the patient had 
lived for sixty years in excellent health, using animal food, which, 
however, he had been latterly induced to change for farinaceous 
diet and milk. For a few days this agreed tolerably well with him, 
and then he began to be tormented with colicky pains, flatulence, 
I sour eructations, and other distressing symptoms. His physician 
; gave him some purgative medicine, and he passed a large quantity 
of tape-worm with relief: the treatment was persevered in, his 
former mode of living resumed, and he recovered quickly. This 
case bears strongly against the fanciful hypothesis that the ova of 
worms are transmitted in the act of generation ; for how could it 
be possible that the ovum of this tape-worm, transmitted in this 
manner, could remain undeveloped in the system for the space of 
sixty years? This case derives additional interest from the fact of 
a change to a farinaceous diet being apparently connected with the 
formation of worms. 

Another remarkable case is given by the same author. The 
patient was a married female who had twelve children — six boys 
and six girls. This woman observed, that whenever she Was preg- 
nant of a girl she had a great longing for milk and farinaceous 
food, and lived on these articles of diet almost exclusively. After 
living in this way for some time, she uniformly got an attack of 
I worms ; and this, as well as the longing for vegetables, coincided 
j with the birth of a female child so invariably, that she was able to 
ij tell with certainty whether the child she carried was a male or a 
j female. This is a singular and well authenticated fact. 
J We come now to the treatment of worms. Generally speaking, 
j this is extremely simple — the principles of treatment in the various 
j kinds of intestinal worms being nearly the same. Simple as they 



220 STOKES'S THEORY AND PRACTICE. 

are, however, some persons entertain false notions respecting them. 
They appear to think that all they have to do is to evacuate the 
worms ; and, having accomplished this, they rest satisfied, and take 
no steps to prevent their recurrence, But the mere evacuation of 
worms is no proof of a cure; to effect this you must prevent their 
return. From what you have learned with respect to their exciting 
causes, you will be able to give such directions as to the patient's 
mode of living as will obviate their recurrence ; and, with regard 
to the means to be adopted for removing them, we may divide them 
into the following: — We have, in the first place, what is called the 
mechanical treatment ; next, the specific ; and, lastly, the purgative 
treatment. The first and last are nearly connected. For instance, 
purgatives appear to act in the same way as mechanical anthel- 
mintics, by irritating the mucous surface of the intestine and the 
worm, and thus causing its dislodgement and expulsion. 

Among the principal mechanical anthelmintics are filings of tin, 
cowhage, powdered charcoal, and crude mercury ; among the spe- 
cific are a variety of substances, most of which have a strong and 
peculiar smell. This is a very curious fact. Valerian, asafoetida, > 
camphor, ether and other odorous substances, have been found to r 
be anthelmintic ; and the Geoffrc&a inermis, which has been em- 
ployed for this purpose, is remarkable for its strong, unpleasant 
odour. The same thing may be said of tobacco, the oil of cheno- I 
podium or wormseed, garlic, artemisia absinthium, and many , 
others. With respect to purgatives, there is not one in the whole 
list, particularly those of the drastic kind, which may not be looked 
upon as an anthelmintic. 

It is the opinion of the most eminent men, that the thread-worm 
is the most difficult to expel, because they are generated with an 
extraordinary rapidity, and accumulate in a very short space of 
time. You are satisfied of their existence, have seen them in the 
alvine discharges/and the patient has all the ordinary symptoms, a 
Well, what is the best way of getting rid of them 1 You shall ; 
commence by the exhibition of a mercurial. It is difficult to ex- \ 
plain why it is that mercury has such an effect in removing these \ 
worms, but the experience of the best practitioners can be adduced p 
in proof of its efficacy. The statements of Dr. Latham of London, i 
and of many practitioners in this country and on the continent, go : 
to prove this. In whatever way it acts, mercury appears to be a 
powerful anthelmintic ; and it is a fact, that these worms have been b 
expelled where it was given in very small doses, and not sufficient 
to operate as a purgative. The best plan is, first, to give a mercu- 
rial purgative, and then to have recourse to the mechanical treat- \ 
ment — giving, with this view, the syrup of cowhage, one of the 1 
most efficacious of this class. It is a remedy which is easily ma- i 
naged, and will do no harm ; for, though it produces violent itching 
when applied to the cutaneous surface, it produces very little 
sensible effect on the intestinal mucous membrane. The form 
which I employ is the following : — Take of the hairs of the doli- m 



SYMPTOMS OF INTESTINAL WORMS. 



221 



I chos pruriens one scruple, syrup of orange-peel an ounce ; of this 
an electuary or syrup is to be made, of which you may give a child 
I a tea-spoonful three times a day. This is the remedy on which the 
' West Indian practitioners, who have frequently to treat this affection 
in the negroes, place the greatest reliance ; and you will find that, 
j if you employ it, a vast number of worms will be often passed. It 
1 should be continued for two or three days, and then a purgative 
! must be given, after the operation of which it may be again resumed 
! if necessary. An excellent adjuvant to this is the use of aloetic 
j injections, composed of two parts of milk and one of the decoction 
' of aloes. In this way you will be able to remove a vast quantity of 
| these little animals from the rectum. It has also been observed, 
that injections of cold fresh or salt water have a great power in 
promoting their expulsion. Bremser mentions, that, in cases where 
these worms pass from the rectum into the vagina in females, and 
excite irritation, there is nothing so effectual in destroying them as 
injections of cold water and vinegar. This you should bear in 
, mind. You should also remember, in the case of administration of 
syrup of cowhage, to give strict orders not to let any of it drop on 
the child's skin, as it would excite a great deal of irritation. You 
should forewarn the attendants of its effects on the skin ; and if any 
j of it should be spilled on the hands, neck, or face, the best thing is 
j to wipe and wash the part well, and then rub it with a little almond 
oil. 

For the expulsion of lumbrici there is nothing so successful as 
1 the ordinary purgative treatment. A bolus, composed of calomel, 
rhubarb, and jalap, will answer this purpose extremely well ; you 
may also use the syrup of cowhage with much advantage. Brem- 
ser gives a formula for an electuary, which I have not tried, but 
have no doubt of its value, for it appears to combine all the qualities 
of a good vermifuge electuary. It is made as follows : — Take of 
the seeds of santonicum, and of the flowers and leaves of tansy, 
reduced to pow r der, each half an ounce. Here you have two anthel- 
I mintics of the specific kind. Add to these two drams of powdered 
valerian: here is another. You then combine with these two drams 
I of sulphate of potass and a dram and a half of jalap : these are 
| purgatives. You then make them up into an electuary with syrup 
of squill, which is also an anthelmintic of the specific kind. Of 
this electuary two or three tea-spoonsful are to be taken during the 
course of a day. Bremser states that this combination is of great 
value, particularly against lumbrici and tape-worm. 

The treatment of tape-worm is not difficult. All the specific and 
\ mechanical anthelmintics are useful in promoting its expulsion, but 
i there is nothing which appears to have such a powerful effect as 
! full doses of turpentine and castor oil. This constitutes the best 
I remedy we possess against the taenia ; but, if you wish to get rid of 
I it entirely, you must give the turpentine in full doses. You will 
frequently be astonished at the vast quantities of this worm which 
will be passed. When you give turpentine, it is safer to order a 

20 



222 



STOKES'S THEORY AND PRACTICE. 



full dose of it; for, if it be given in small quantities, it is very apt 
to irritate the urinary organs. Half an ounce of turpentine, with 
the same quantity of castor oil, form an efficacious though very 
disagreeable draught. You may, however, obviate its nauseous- 
ness by the addition of a small quantity of camphorated tincture of 
opium and mucilage of gum arabic. The celebrated empyreumatic 
oil of Chabert is, in my mind, nothing more than a modification of 
the turpentine. This is the remedy which Bremser looks upon as 
most efficacious against the tape-worm. You have all, I presume, 
heard of the animal oil of Dippel — the oil which is produced by 
the distillation of bones or hart's-horn shavings. To one part of 
this are added three parts of turpentine ; these are left to combine 
for four days and then distilled; the first three parts of oil which 
come over are called the empyreumatic oil of Chabert. It is an 
exceedingly nauseous remedy, has a most disgusting smell, and is 
seldom used in this country. Bremser recommends it to be taken 
in doses of a tea-spoonful three times a day. S.ome persons who 
have tried it have assured me that it is extremely difficult to be 
taken, and that it excites a train of most disagreeable abdominal 
sensations. Bremser, however, thinks highly of it; he is in the 
habit of directing his patients to take it for three or four successive 
days, then to omit for a day or two, and then to return to it again; 
and he says that it not only succeeds in evacuating the worm, but 
also in preventing its return. In addition to this, he recommends 
the use of a fortifying tincture, which I think very useful in worm 
cases. It is a combination of one of the salts of iron with a pre- 
paration of aloes. If you take equal parts of the muriated tincture 
of iron and tincture of aloes, you will have a remedy somewhat 
similar to the strengthening tincture of Bremser. Twenty drops 
of this mixture, taken three or four times a day, will prevent the 
recurrence of worms. * 

* [ I have prescribed with advantage sulphate of copper in a case of tsenia. I 
may premise that my patient was captain of the vessel in which I went to China, 
as surgeon. He had used various remedies without much effect. I first gave him 
full doses of calomel and gamboge, from which he derived no benefit. I then 
began the use of the carbonate of iron, which, by the way, in conjunction with 
calomel, I find the best vermifuge against lumbrici. Of the carbonate of iron he 
took, in gradually augmented quantity, until the last dose amounted to half an 
ounce. This was given at night, ahd was followed by no perceptible change of 
any of the functions, except that the pulse was much diminished in force the next I 
morning, at which time there was a motion of the bowels. After an interval of 
three days, in which a powder of calomel and jalap, each ten grains, was given, 
I began the use of the sulphate of iron, six grains combined with half a drachm 
of the carbonate, and continued to give the two daily for a fortnight; gradually 
increasing the dose of the sulphate until it reached a hundred grains, — the common 
dose of the carbonate during the time being one drachm. Occasionally calomel 
was added to the powder of the two preparations of iron, with the effect of acting 
freely on the bowels ; but no portion of worm was passed. The patient did not 
complain of any nausea, nor did he vomit after taking the sulphate of iron in these 
doses, except in the two last mornings. The last dose which he retained 
was eighty grains, taken at night, and followed in the morning by some 
nausea and a feeling of roughness in the oesophagus. The hundred-grain dose was 



i 



PAINTERS' COLIC. 



223 



In our next lecture, I shall take up the subject of painters' colic, 
and some other affections connected with the viscera of the abdo- 
men, and then pass on to the consideration of thoracic diseases. 

[This last intention was not carried out by the lecturer at the 
time ; and hence the effort made by the editor to supply, in part, 
this omission.] 



LECTURE XXI. 

Painters' colic — Effect of metallic poisons on the nervous system — Symptoms of 
painters' colic — Pathology of neuroses — Action of lead on the system — Abdominal 
and cerebral symptoms — Species of painters' colic — Dr. Thomson's researches on 
lead — Effects of in animals — Effects of on the generative system. 

j A great deal of our time has been already occupied with the dis- 
eases of the digestive system — in fact, much more than I originally 
intended ; the only apology I have to make for this, is the deep 

i and paramount importance of the subject. Before I quit this part 

j of the course, there are yet one or two subjects to which I shall 
briefly allude, namely, peritonitis and painters' colic, With respect 

, to the first of these diseases, I shall say but very little ; the ordinary 
form of peritonitis is a disease so well known, and so fully treated 
of in books, that it would be only a waste of time for me to go over 

I thrown up, but without being followed by further vomiting". On the day after 
this he took twenty grains of calomel in the evening, which procured two motions 
the next morning. I then began with the sulphate of copper in a dose of half a 
grain, and continued its use daily for a fortnight, gradually increasing the quantity un- 
til it reached five grains. This last dose caused nausea, pain of the head in the night, 
and on the following morning headache and a feeling ofgreat lassitude. To each of the 
two last doses, four grains and five grains, were added twenty-five drops of laudanum. 
It may be mentioned that these medicines were all given in the evening, partly on 
account of their being better retained in the stomach at that time, and mainly in 
conformity with the wish of the patient, to whom it was of less moment to be sick- 
ened in the night than during the day, in reference to his professional duties. 

As to the vermifuge effects of the sulphate of copper, my memorandum of the 
case shows that on the very first morning after beginning the medicine, half a 
grain combined with ten grains of rhubarb, there was a discharge of many lum- 
brici. After the second dose, as above, a portion of taenia, about a foot and a half 
long, was discharged, and the bowels were also freely moved as they had been the 
preceding day. After the fourth dose, still as above, about four feet of taenia were 
passed at the first stool in the morning. The dose of the sulphate was increased 
to a grain : and on the fourth day, and after the third dose, there was passed about 
four yards, in three portions, of the tape-worm. From this time the dose was 
increased until, as already mentioned, it amounted to five grains, but without 
causing the discharge of more taenia. Commonly the bowels were moved regu- 
larly once a day — sometimes twice or thrice after the sulphate. The reason of 
my adding the few grains of rhubarb to the salt of copper, was the better to dis- 
guise the medicine from the patient. There was no fallacy in the doses throughout 
the case, for I weighed them and gave them myself. 

After our arrival at Canton I presented to the captain spirits of turpentine in doses 
of half an ounce, two or three times, with good effect. Once some of the worm was 
discharged ; after that he felt himself much better, and was for a long time, some 
years, clear of the symptoms of taenia. — B.j 



224 



STOKES'S THEORY AND PRACTICE. 



it ; and with respect to peritonitis from perforation, all the original 
information I could communicate on this part of the subject, may 
be seen in one of my published clinical lectures, and in the article 
on Peritonitis from Perforation, in the London Cyclopaedia of 
Practical Medicine. The ordinary form of peritonitis has been 
described in this work by Dr. M'Adam, the disease from perforation 
by myself. I shall therefore pass over this subject, and proceed to 
the consideration of a very interesting disease — painters' colic. 

This disease is called painters' colic, from the circumstance of 
house-painters being extremely liable to it from coming into fre- 
quent contact with the poison of lead. Its synonyms are numerous, 
dry colic, Saturnine colic, rachialgia metallica, Devonshire colic, 
&c, &c. 

Painters' colic is an example of the effects of a metallic poison 
on the nervous system. There are certain metals which produce 
a powerful effect on the system, not by means of their corrosive 
properties, or by any direct action on the surface to which they are 
applied, but by a peculiar impression made upon the nervous 
system. Thus we find that mercury, under certain circumstances, 
will give rise to a very singular nervous disease ; arsenic may be 
introduced into the system in such a way as to produce symptoms 
of nervous lesion ; copper exercises a similar morbid influence, 
and the effects of lead are universally known. I do not mean to 
say that all these metals produce similar effects on the economy, 
for this is not the case ; but there is one point of agreement between 
them, that all may produce symptoms which are called nervous or 
neurotic, and the diseases thus produced are classed among the 
neuroses. What is the meaning of this term neurosis 1 A lesion 
of nervous function, more or less complete, occurring independ- 
ently of any demonstrable organic change. A neurosis, then, is 
an alteration in the functions of the nerves of organic and animal 
life, the nature of which alteration we cannot understand, neither 
can it be demonstrated by the knife, nor by any examination of the 
state of the nervous tissue. In other words, a person will die with 
the symptoms of a neurosis ; and when you come to examine the 
body, you will be unable to detect, in the minute ramifications of 
the nerves, the trunks, or the nervous centres, any appreciable 
lesion. 

Diseases of this description have been divided into two classes — 
active and passive neuroses. Active neuroses signify an increase 
or exaltation in the nervous function; passive neuroses are those in 
which there is a diminution of nervous energy ; in both, there is an 
absence of perceptible organic change. Take, for instance, an 
example from the nerves of animal life : a case of convulsions, 
independent of organic disease, is an example of the active neurosis ; 
a case of paralysis, under simiiar circumstances, is an example of 
the passive. In the former, there is an exaltation of the nervous 
function, which is reflected upon the muscular system ; in the 
latter, there is a diminution, producing a partial or total loss of the 



PAINTERS' COLIC. 



225 



power of motion. It has been asserted, by eminent physiologists, 
that passive neurosis can only exist in the organs of the life of 
relation, because the functions of the ganglionic system, which 
presides over organic life, cease only at the death of the individual. 
But there may be such a thing as semi-paralysis of the organs to 
which the ganglionic nerves are distributed ; and hence we may 
have passive neuroses of the system of organic as well as of animal 
life. We get a good idea of these neurotic affections, by taking 
some of the most remarkable instances of this kind. Hydrophobia 
is a remarkable instance of excessive lesion of the nervous function, 
without any known organic change ; so is tetanus, and so are some 
forms of apoplexy, convulsions, and mania. Here we have violent 
irritations of the nervous system, in which there is no perceptible 
organic change ; and where the only information we derive from 
pathological anatomy is of a negative character, telling us what 
these diseases are not, and leaving us, as to their actual nature, as 
much in the dark as ever. We find by dissection that hydrophobia, 
and tetanus, and hysteria, and convulsions, and apoplexy, are not 
caused by inflammation of the brain or spinal marrow, and that is 
all. Hydrophobia, tetanus, convulsions, and hysteria, are instances 
of active neurosis ; paralysis and apoplexy, without any known 
cerebral disease, are looked upon as examples of the passive kind, 
because they present either a diminution or abolition of the nervous 
function. 

In the present state of medical science, we must admit this 
division of the affections of the nervous system' into diseases with 
and without perceptible organic lesion. I grant that it is very diffi- 
cult, when we come to consider alterations in the functions of parts, 
to conceive how such changes could be effected without molecular 
alteration, or that the brain could be deranged in its functions, 
without some change of this kind. We are, however, compelled t©. 
consider such functional alterations of the nerves as chansres with 
which we are unable to connect any process of hardening, or soft- 
ening, or anomia, or congestion, or, in fact, any known pathological 
condition. Rostan is of opinion that all diseases are organic ; that 
is to say, that they are produced by some molecular change, and 
this, he says, should be the basis of medicine. Unfortunately for 
medicine, it has been given so many bases, that it sometimes knows 
not what leg to stand on. 

But to return to our subject. Painters' colic is an example of a 
neurosis, that is to say, it is a lesion of the nervous function, uncon- 
nected with any known pathological alteration. It presents, com- 
monly, two periods — the first exhibiting the phenomena of active, 
the second of passive, neurosis; or, in other words, the signs of 
exaltation of the nervous function precede those of depression. In 
the majority of cases, we find the first stage of this affection charac- 
terized by violent spasm, pain and convulsions, symptoms indicative 
of active nervous lesion ; whereas in the second stage we have 
paralysis, the diagnostic mark of the passive kind. This is the 

20* 



226 STOKES'S THEORY AND PRACTICE. 

order in which the phenomena of painters' colic are generally met 
with, but in some cases the first stage is either very imperfectly 
shadowed out, or even entirely wanting ; the paralysis comes on in 
an insidious manner, and without being ushered in by any symp- 
toms of exaltation of the nervous function. 

In this country, the most common victims to this disease are 
painters, who are much in the habit of working in white lead, and 
when you are connected with the management of any public 
medical institution (as I hope you will all be), you will often have 
to treat cases of this description. In Dublin, and all large cities, it 
is an exceedingly common affection, and the patients are for the 
most part house-painters. Next to these, the persons who are most 
subject to it are plumbers, and those who are employed in the melt- 
ing of lead. 

When the poisonous particles of lead enter the system in a highly 
volatilized state, its morbid effects are more certain and extensive. 
Every house-painter will tell you that the kind of work which is 
most likely to produce a deleterious effect, is painting "the dead 
white" or, as it has been termed, statuary white. In doing this, 
they use white lead combined with a large proportion of the oil of 
turpentine ; and, in order to produce the intended effect, they are in 
the habit of excluding the air as much as possible. By means of 
the turpentine and the warm temperature of a close room, the lead 
is volatilized, and, in this state, appears to have an extraordinary 
power of impregnating the system. Some of the very worst cases 
of painters' colic are produced in this way. Painting in the open 
air, even where the same preparation is employed, is comparatively 
harmless. A poor fellow, who was for a considerable time under 
my care, assured me that he had escaped for twenty years, and was ! 
convinced that he would have enjoyed a much longer immunity, 
had he not been put to work at the statuary while in a close room. 

With respect to plumbers, it is now ascertained that this disease 
is of comparatively rare occurrence among them ; and the reason 
of this is, that they generally work in the open air, or in well ven- 
tilated apartments, and have now but little to do with the actual 
manufacture of lead. The kind of lead which they generally use, 
sheet and pipe lead, is furnished from the manufactories, and their 
occupation principally consists in the moulding and soldering of 
it. We very seldom now see a plumber labouring under colic. 

Painters' colic may be observed under a great variety of forms ; 
but, for the convenience of studying the disease, we may divide 
these varieties into four classes. In the first, we have the pheno- 
mena of simple colic, without any obvious or marked symptoms of 
bilious, gastric, or cerebral derangement. In the second variety, 
the disease assumes a more decided character ; the colic is compli- 
cated with symptoms of fever of a gastric character, the pain in 
the belly is more acute, the constipation more obstinate ; there is 
pain and difficulty in going to stool, nausea and vomiting, with oc- 
casional headache, dyspnoea, and sense of constriction about the 



PAINTERS' COLIC. 



227 



preecordia: the belly is hard and retracted, and there is often pain 
in passing urine. In the third variety we have a more formidable 
array of symptoms. The functions of the brain and spinal marrow 
are deranged ; there are wandering pains in the extremities ; and. 
the patient has frequent attacks of violent convulsions, resembling 
those of epilepsy. He also labours under the abdominal symptoms, 
but in this stage they are not so well marked, or so distinct, as in 
the former ; the lesions of the functions of the cerebro-spinal system 
begin now to exhibit a greater degree of preponderance, and claim 
the principal share of the attention of a symptomatologist. In the 
fourth variety there is paralysis, without being preceded by the 
ordinary symptoms of abdominal or cerebral derangement. A 
medical friend of mine met with a case of this kind not long since. 
He was called to visit a child who had lost the use of his limbs. 
He went, and found the child lying in bed perfectly quiet and easy, 
! his intellect sound, and his spirits good, but labouring under com- 
plete paralysis of all his limbs. He inquired minutely into the 
history of the case, and made a most scrutinizing examination, but, 
from all he could see or learn, there was not the slightest ground to 
suspect disease of the brain or spinal cord. There had never been 
any symptoms of colic. He was puzzled with the case, and tried 
: one thing after another without benefit. At length he found out 
that the child's father was a painter by trade, and this led him to 
j suspect that the symptoms might have some connection with the 
I poifon of lead. He inquired; and was told by the mother, that a 
I quantity of white paint had latterly been kept in the room, and that 
it was impossible to keep the child from it. He instantly had the 
paint removed, a free current of air admitted into the room, and by 
the use of purgatives, assisted by stimulating frictions, the child 
recovered. 

The following is the order of symptoms generally observed in 
this disease. First, we have the precursory, denoted by pain and 
sensation of weight about the epigastrium ; a weak, small pulse ; 
general languor and weakness of the muscular system ; want of 
appetite; cold, clammy skin; a tremulous and coated tongue. At 
this period there is sometimes diarrhoea. Then comes some excit- 
ing cause, exposure to cold or wet, excess in eating or drinking, 
and the disease sets in with more or less intensity. The patient is 
attacked with dreadful pain in the belly, which differs from the 
pain of inflammation in this, that, so far from being increased by 
pressure, it is in most cases relieved. In fact, so decided is the 
relief produced in this way, that there is a case on record in which 
: the patient used to get the greatest ease by making one of his 
j fellow-workmen stand upon his belly. This relief from pressure 
, is very generally observed in colicky affections. Indeed, so general 
is it, that you will hear it frequently slated, that all cases of colic 
, are relieved by pressure. This, however, is not invariably true ; 
for I have seen cases where the patients could not bear pressure, 
and where it required a careful examination to distinguish the 



228 



STOKES'S THEORY AND PRACTICE. 



symptoms from those of inflammation. The pain is of a twisting 
kind, and felt about the umbilicus; and, in connection with this, 
there is scanty urine, with more or less pain in passing it, obstinate 
constipation, and a tense, hard, retracted state of the belly, from the 
violent contraction of its muscles. The upper portion of the belly 
is sometimes more retracted than the lower, and the pulsations of 
the abdominal aorta are unusually distinct. The pain remits, and 
then becomes exacerbated, and the patient's countenance is expres- 
sive of acute suffering. In that form of the disease where there is 
a complication of gastric or bilious symptoms, the patient has a 
semi-jaundiced look, a hot moist skin, quick pulse, foul tongue, 
vomiting, hiccup, thirst, and epigastric tenderness. 

In the third form, the chief force of the poison seems to be directed 
against the brain and spinal cord. There is vertigo, headache, 
stupor, and sometimes delirium ; the patient has fits resembling 
those of epilepsy, but of longer duration, and violent convulsions, 
which sometimes continue with unabated intensity for twelve, or 
even twenty-four hours. You will see those unfortunate creatures 
rolling and twisting in every form, sometimes doubled forwards, 
sometimes in a state of perfect opisthotonos, sometimes moving 
their limbs with the convulsive action of an epileptic, and foaming 
at the mouth. In addition to this, it is stated, in the descriptions of 
this disease, that the patient loses his sight, and becomes amaurotic ; 
this I can confirm, for I have seen it more than once. It is a 
curious fact, too, that this blindness may come on before the other 
cerebral symptoms are developed. I recollect a case in which one 
of the first symptoms was blindness. The patient happened one 
evening to be indulging himself in whiskey-punch, and was in a 
fair way of getting comfortably drunk, when, unfortunately, he 
found that all of a sudden he could neither see single nor double. 
He groped about in a very disconsolate state for his glass, but not 
finding it, and finding, at the same time, that he had lost his sight, 
he came to the hospital next morning, and shortly after his admis- 
sion, had a violent attack of convulsion. In cases of this kind, I 
have generally found the pupils contracted. The patients toss 
about in bed, and are frequently found lying with their heads turned 
towards the foot of the bed. In some cases, the breathing has been 
stertorous for a length of time, and the head fixed, but the fingers 
and hands were flexible. I have seen cases in which the coma dis- 
appeared, and was followed by perfect blindness, lasting for two or 
three days, and then yielding to treatment. 

These symptoms, striking and extraordinary as they are, do not 
seem to depend on the same state of the brain as cases of other dis- 
eases which are accompanied by sanguineous determination to that 
organ. The reason I make this assertion is, that many of the most 
violent nervous symptoms, including profound coma, subside under 
the use of a stimulant treatment. I think we may look upon these 
symptoms as similar to what are termed the symptoms of the 
nervous apoplexy of the ancients, A case of this kind, which 



PAINTERS' COLIC. 229 

occurred in the Meath Hospital, is deserving of notice, from the 
singular effect produced by treatment. The patient was in a state 
of profound coma, but the head was cool, and the arteries had no 
inordinate pulsation. If this was a case which presented the other 

I symptoms of apoplexy, I would have prescribed bleeding, leeches, 
and cold applications. But I reasoned thus — Here is a case in 

! which there is no evidence of the existence of inflammatory action. 

| Opium has been found to relieve the abdominal symptoms of the 
disease — may it not also relieve the cerebral] I ordered the patient 
to have a free dose of laudanum in camphor mixture. In a few 

! hours he awoke, sat up in his bed, and next morning we found the 

I symptoms of coma had completely disappeared. In two other 
cases of a similar kind, I have given opium and carbonate of am- 

I monia with the most favourable result. 

Dr. Clutterbuck mentions a peculiar symptom of this disease — a 

1 kind of gouty inflammation attacking the great toe, and followed 
by relief. I have not seen this. He states that the first joint of the 

• great toe becomes red, hot, painful, and swollen, and that this 
remits by day and returns again at night. I have never seen this, 

| nor have I ever seen those hard tubercles on the tendons in various 
parts of the body, which some authors have described. 

After these symptoms, w 7 e come to a new class, namely, the pas- 
sive, characterized by paralysis of the muscles of animal life. It is 
remarkable that this paralysis seems to be principally a paralysis 
of motion, and that the power of sensation is seldom or never 

! impaired. Generally speaking, the upper are more subject to 
paralysis than the lower extremities, and the right than the left 
arm. The latter circumstance is explained by assuming that the 
direct influence of the poison is more applied to the right arm. 
The paralysis of the arm is also frequently partial ; the extensors 
lose their power, but the flexors do not in so great a degree. You 
will see a patient with his arm hanging by his side as if it were 
dead, but if you give him anything to hold he can grasp it firmly. 
I have known painters continuing to work with a semi-paralysed 
arm. There is also an atrophied condition of the affected part; 
and this sometimes comes on with such rapidity, that, in the space 
of a week or ten days, the affected limb will be scarcely half as 
bulky as the corresponding one. We cannot account for this 
remarkable emaciation on the principle of loss of motion alone, for 
the short space of time in which it occurs, in many instances, is 
opposed to our entertaining such an opinion, and we must look for 
some other explanation. On this point, science affords us no satis- 

j factory information. 

This disease, notwithstanding all its terrible array of symptoms, 

| is very seldom fatal. Hence the uncertainty which long prevailed 

| as to its pathological nature. In the great majority of cases, where 

I a dissection was made, the patients died of some other disease, 
which either occurred during its course, or had preceded it. All 
that appears to be established at present is, that there is no known 



230 



STOKES'S THEORY AND PRACTICE. 



organic change of the nervous system connected with this disease ; 
that it occurs in all its forms without the co-existence of organic 
lesion, and that its exciting cause is the poison of lead. 

It was formerly supposed that all the preparations of lead, 
whether applied externally, or used internally, were capable of 
producing colic, but this doctrine is at present considered very 
questionable. It was thought that metallic lead, and all its salts, 
were capable of causing the disease ; but the morbid influence of 
this metal is now restricted by the best chemists and pathologists 
chiefly to its carbonate. This opinion, I believe, was first put for- 
ward by Dr. A. T. Thomson, the author of the London Dispensa- 
tory, in an interesting paper published by him in the tenth volume 
of the Medico-Chirurgical Transactions. The object of this paper 
is to prove that, of all the preparations of lead employed in phar- 
maceutical and other purposes, the carbonate is that which is 
chiefly poisonous, and that the acetate and sub-acetate are com- 
paratively harmless. 

You have all, I am convinced, heard of cases of colic produced 
by the external use of the acetate of lead, and you will see some 
cases in proof of this opinion in Darwin's Zoonomia, and other 
writings. There is a case on record of a woman, who having 
poulticed her ankle with this preparation, for the cure of a sprain, 
got colic and fell into a state of marasmus. I knew of a deplorable 
case of burn affecting the abdominal integuments, which was treated 
with a solution of the acetate of lead. After using it for a fortnight 
or more, symptoms of colic came on, which not being recognised, 
the lead wash was continued, and the woman died in great agony. 
Dr. Thomson explains all this in a very satisfactory way. He 
shows that the solution of acetate of lead, when exposed to the air, 
attracts a quantity of carbonic acid, and is thus converted into a 
carbonate; of this I have very little doubt, for you will find that, 
by exposing a solution of the acetate of lead to the full influence of 
the air, the carbonate will gradually be deposited in the shape of a 
white powder. In the same way we can understand why it is that a 
solution of the acetate of lead, added to fermenting poultices, may 
be converted into a carbonate by the carbonic acid which is evolved. 
It is also a fact, that the acetate can be used internally for a long 
time without producing anything like deleterious effects. I have 
given it for weeks together in full doses, without its having been 
ever followed by colic, or any symptoms characteristic of the ab- 
sorption of a poisonous matter. There are cases on record where 
as much as six drams of this salt have been taken internally with- 
out-producing any sensible morbid effect. As far as my experience 
goes, all those cases, in which the medical use of the acetate of lead 
has been attended with disagreeable symptoms, were cases in which 
it had been used as an external application. There were two cases 
in the Meath Hospital in which this medicine was used externally, 
in which colic, and other indications of poisonous absorption, took 
place, but not a single one in which its internal employment had 



PAINTERS' COLIC. 



231 



been injurious. An excellent practical rule is laid down by Dr. 
Thomson, that, where you wish to employ the acetate oflead inter- 
nally, you should take care to combine it with diluted acetic acid. 
Of the two combinations of lead with acetic acid, the sub-acetate is 
most liable to be decomposed and converted into a carbonate, so 
that, if you prevent this by mixing with the sub-acetate, or acetate, 
a certain quantity of distilled vinegar, there will be little or no 
chance of unpleasant symptoms being produced, even where the 
medicine is given in very considerable doses. We are, therefore, 
I think, justified in concluding that it is the carbonate of lead which 
is productive of poisonous effects; and that where bad symptoms 
have resulted from the use of the acetate, it was in consequence of 
its being converted into a carbonate. I must, however, remark, that 
it has not been sufficiently proved, as yet, that the use of the acetate 
is perfectly safe. 

It is an interesting fact, that many of the lower classes of animals 
are subject to this disease. Burserius was one of the first authors 
who directed the attention of medical men to this singular occur- 
rence. I have got from my father an abstract of some observations 
made by him on this subject, during a visit to the lead hills in 
Scotland. He found that, in the pastures among these hills, and in 
their immediate vicinity, cows, horses, sheep, dogs, and even poul- 
try, were subject to colic from lead. The symptoms, also, in these 
animals were observed by him to bear a very close analogy to those 
of the human subject. Thus, for instance, in cows there was obsti- 
nate constipation with suppression of urine ; the poor animals seemed 
to suffer from violent twisting pain in the belly, and sometimes were 
thrown into a state of furious excitement, running wildly across 
the country. He learned, also, that during that period it was cal- 
culated that at least one tenth of the cows in this situation had died 
of the effects of the poisonous absorption of lead. One of the most 
ordinary precursory symptoms, was the animal becoming what is 
called hide-bound ; this was followed by obstinate costiveness, and 
there was much apparent suffering, with panting, starting, and 
slavering from the mouth. Where the cerebral symptoms were 
most prominent, the signs of abdominal irritation were by no means 
distinct ; and this, as I have remarked, is the case in the human 
subject. In some, who had the head affected, and ran wildly 
through the country, the secretion of milk was stopped ; and this 
accords, too, with the effect oflead on the human female. Another 
remarkable circumstance is, that animals living in the vicinity 
of these lead hills have exceedingly difficult labours. Sheep are 
subject to epileptic convulsions and paralysis; dogs have the head 
principally affected, they run across the country slavering at the 
mouth, as if in a state of hydrophobia, but they do not bite, and are 
in all respects perfectly harmless. In barn-door fowl, the genera- 
tive function was injured, and the hens reared or brought there 
ceased to lay eggs. 

There is one fact, mentioned in these observations, which tends 



232 



STOKES'S THEORY AND PRACTICE. 



to confirm the opinion of Dr. A. T. Thomson, that the poisonous 
effects of lead are produced chiefly by the carbonate. A distance 
of very few miles from the valley renders animals quite free from 
any liability to the disease ; but if they should happen to stray into 
the immediate neighbourhood, and particularly into a portion of low 
ground, flooded during the winter months by a river which runs 
along the valley from the mines, and which, in all probability, 
leaves behind an efflorescence of the carbonate of lead, they are 
very liable to be affected with colic. It is said, also, that the poison 
is produced by the volatilization of lead in the smelting houses, the 
vapours of which are carried down the valley and through the 
neighbouring parts. Be this as it may, the Gaelic name of the 
valley signifies the poisonous vale ; and, as it is very probable that 
this name had been given in consequence of the deleterious qualities 
of the place long before the establishment of lead works, it tends 
strongly to favour the opinion that it is the water which contains 
the poison. 

The mode of cure employed by the shepherds in this place, is to 
give strong purgative injections, and remove the cattle from the 
influence of the poison, by sending them to new and healthy pas- 
tures. In this way they frequently recover ; and if we look to 
the cause of the disease, its symptoms, or mode of cure, we shall 
observe a striking analogy between it and the colic from lead in the 
human subject. 1 shall conclude this subject at my next lecture, 
and then go on to diseases of the chest. 



LECTURE XXII. 

Pathology of painters' colic — Researches on the state of the nervous and digestive 
systems — Treatment — Use of narcotics, purgatives, tobacco, &c, &c. — Treatment 
of paralysis from lead — Efficacy of strychnine and brucine — Colic from copper 
— Poisonous effects of mercury — Remarkable case — Affection of the respiratory 
muscles. 

We were occupied at our last lecture in considering the symp- 
toms of painters' colic. I mentioned that it occurs under a variety 
of forms; that the symptoms are to be attributed to a lesion of 
nervous function independent of any known organic change ; and 
that the same disease may be seen in animals which have been 
exposed to the poison of lead. There are some other facts con- 
nected with this disease, which should not be passed over, and 
which I am anxious to lay before you previously to entering upon 
the treatment. 

You will recollect that I introduced the subject by stating that 
painters' colic belonged to the class neuroses, and that I endea- 
voured to show that this implied a lesion of function of any part of 
viscus of the body, frequently characterized by the most decided 
departure from the natural condition, and yet unaccompanied by 



PAINTERS' COLIC. 



233 



perceptible organic change. I said, also, that it was hard to sup- 
pose the existence of great functional alteration, without any mole- 
cular change ; but that, in the present state of science, we are 
compelled, for the want of a better term, to call these affections 
neuroses, in contradistinction to diseases in which there is organic 
lesion visible. To illustrate this point, take an example from two 
different cases. In one case of what is called dyspepsia, we have 
j inflammatory, or, at least, sub-inflammatory derangement of the 
J stomach: here the disease is traceable to organic change; in another 
j we have symptoms of nearly the same character, and yet there is 
j no organic lesion. Painters' colic comes under the latter head; 
. we observe symptoms of excessive functional lesion, but dissection 
does not exhibit any organic change. Pathological anatomy tells 
j us what it is not, and we arrive merely at a negative knowledge of 
its nature. We have decided proofs of extraordinary lesions of the 
i nervous system, and yet, when we come to the post mortem exa- 
mination, we cannot find any visible change to account for these 
striking phenomena. 

The old pathologists maintained that spasm of the intestines 
was the principal cause of the disease, and attributed the symptoms 
to their contraction. This opinion appears to have some founda- 
tion, when we consider the violent symptoms of colic which accom- 
pany this affection. Dubois de Rochfort has mentioned, that in 
such cases he has found intussusception of the intestines. De 
Haen says that contractions of the colon are very common ; and 
] several authors make the same assertion. The results of more 
modern observation, however, are against these opinions. I have 
told you already, that in consequence of this disease seldom or 
never proving fatal, there is a degree of doubt attached to its pa- 
thology; but it is an interesting fact, that where death from other 
causes has occurred during the existence of painters' colic, the 
digestive tube has been found either in its healthy state, or with a 
few detached spots of vascularity, without any decided inflamma- 
tory character, and totally insufficient to account for the symptoms. 
This, which is all that pathological anatomy reveals, may be consi- 
dered as purely accidental, and only of occasional occurrence, so 
that we are compelled to look upon the disease as one in which 
j there is great lesion of function without any organic alteration. 

In the hospital of La Charite, at Paris, a vast number of cases of 
painters' colic have been treated. In the space of eight years five 
hundred cases of this description have been admitted ; out of these, 
five died while labouring under the disease; and the following is 
an abstract of the appearances observed in dissection. In the first 
case, there was rupture of an aneurism of the abdominal aorta, and 
the patient sank from loss of blood. On examination, the digestive 
lube was found in the natural and healthy condition — there was 
neither vascularity nor contraction. The subject of the second 
case died of apoplexy. The whole intestinal canal was found 
healthy, and, contrary to the doctrines of the school of Broussais, 

21 



234 



STOKES'S THEORY AND PRACTICE. 



there was neither congestion nor vascularity. In the third case, 
the patient had fits of an epileptic character, in one of which he j 
expired. The colon exhibited a slight degree of redness, but quite 
insufficient to explain the symptoms during life. In the fourth, the 
cause of death was the same, and, on dissection, the tube was found 
healthy. Another patient, after recovering from the symptoms of 
painters' colic, got a sudden attack of asphyxia and died. His body 
was examined, but there was no trace of disease in the colon or ? 
any other part of the intestinal canal. Here we have five cases in 
which there was either no disease at all in the digestive tube, or, 
if there was any, the amount was quite insufficient to account for 
the symptoms. Louis, in a memoir which he has published, on 
sudden and unexpected deaths, gives a case of this disease where 
death occurred suddenly on the eighth day. The intestines were ( 
found to be in a healthy condition. Martinet gives two cases of | 
persons who died of the cerebral symptoms while labouring under 
this disease ; here, also, the tube was in the normal state. Thus 
we have eight cases with dissections detailed by various authors, | 
all men of high professional celebrity, having no theory to support, j 
and all agreeing in the statement that there is little or no appreci- 
able lesion of the digestive tube ; that in the majority of cases it is j 
in a state of health ; that no contraction exists ; and that such 
morbid appearances as have been found must be looked on as 
accidental. t 

There is one interesting circumstance in these cases which | 
deserves to be noticed. With the exception of the first and fifth 
cases, all the patients presented that form of the disease in which 
the functions of the brain are decidedly injured. Here it seems 
probable that the cause of death was excessive irritation of the 
nervous system. Now, in the observations I made on the cases 
which were treated at the Meath Hospital, you will recollect I . [ 
stated that where the cerebral symptoms were predominant the i 
abdominal were more or less indistinct and latent, and that the ; 
cause of indistinctness, or even total absence, of these might be j'. 
owing to the force of the disease being thrown upon the brain and jr 
spinal cord. Such was the case in the instances above recited, and j 
such we have also seen to be the result in the case of those animals .; 
of an inferior order that have been exposed to the poison of lead. 
How far the predominance of cerebral excitement may explain the ( 
want of appearances of disease in the digestive tube may be a sub- j 
ject of consideration. 

What is the state of science with respect to the brain and spinal 
marrow? Allow me here to call to your recollection the symptoms 
of functional derangement of the nervous centres, the coma, the 
violent convulsions, the amaurosis, the deafness, the delirium, the 
paralysis. All these are violent symptoms, and you would natu- 
rally expect to find them connected with some sensible alteration, 
some congestion, or inflammation, or ramollissement. But nothing 
of this kind can be discovered. In all the cases where death 

f 

i 

i 



PAINTERS' COLIC. 



235 



| occurred under such circumstances, at La Charite, with the excep- 
tion of some slight appearances of cerebral lesion in the second, 
there was no perceptible disease in the brain or spinal cord. The 
membranes and substance of the brain presented their normal con- 
dition ; there was little or no fluid in the ventricles ; the spinal cord 
was healthy and natural in consistence and colour, and there was 

I no effusion into its sheath. All these circumstances led to the 

I conclusion that painters' colic is essentially a neurosis. Observe, 
too, how interesting it is to connect the circumstance of the absence 

j of organic change with the singular fact which I mentioned in my 

! last lecture, that the comatose symptoms of this affection may be 

I treated with stimulants and opiates. Where we have coma with 
congestion of the brain, opium has the effect of increasing the 

I symptoms ; here it was found to have a contrary effect. So that 
our experience and the results of pathological anatomy, as far as 

! they go, appear to square exactly. We see, then, that painters' 
colic is not inflammation of the intestines, or of the brain, or of the 

j spinal cord, and this information, though of a negative character, 
possesses considerable value in a practical point of view. I do not 

I know any cases of what have been termed neuroses, in which the 
bearings of pathological research on practice are so extensive and 
so satisfactory. 

It is a fortunate circumstance that this disease is seldom fatal, 
and it is some consolation to think that, although the patient's suf- 
ferings are dreadful and often protracted, there is little danger of 
i life, and that the complaint is almost always amenable to judicious 
treatment. I have been for some years in the habit of treating it in 
a routine way, and can speak from experience of its success. — of 
course this treatment is to be modified by circumstances. Suppose 
a patient applied to you with violent pain about the navel, a hard 
and retracted state of the abdomen, obstinate costiveness, and the 
other symptoms which characterize an attack of painters' colic ; 
the first thing I would advise you to do is to prescribe a full opiate. 
Many persons would object to this, and say that there is constipa- 
tion enough already, and that opening the bowels would be much 
more likely to give relief But opium does not here add to the 
constipation ; indeed, so far from doing this, it sometimes acts as a 
laxative. At all events, it is a remedy which is perfectly unobjec- 
tionable. Give, then, in the first place, a full opiate, it will have 
the effect of relieving the patient's sufferings, and will enable you 
to gain time for the employment of other means. The next thing 
is to place the patient in a hip bath, and keep him in it as long as 
| possible. Do not neglect this, for I know of nothing that gives 
| more decided relief. I have often seen cases where the patient was 
I quite easy while he remained in the bath, but experienced a return 
i of the pain as soon as he left it. If you have no means of procur- 
I ing a bath in this way ; the next best thing is to have recourse to 
emollient stupes containing some narcotic, after the manner first 
introduced by my colleague, Dr. Graves. One of the best of this 



236 STOKES'S THEORY AND PRACTICE. 

kind is the tobacco stupe ; if you cannot get this you may employ 
poppyheads for the same purpose. The tobacco stupe is much 
better than the tobacco injection, because its effect can be more 
easily regulated, but in violent cases I am in the habit of combining 
both, employing the stupe during the paroxysms of pain, and throw- 
ing up a tobacco enema every four or six hours, until a decided 
impression has been made on the symptoms. In the success which j 
has attended my distinguished friend Dr. O'Beirne's treatment of ( 
tetanus by the use of tobacco we see an analogous effect. In this 
way you will succeed in giving relief; you should also prescribe a i 
brisk cathartic, and this you may do without any fear of injuring \ 
the patient, or exciting intestinal inflammation. The insensibility of i 
the intestines to the stimulus of even powerful purgatives is a cu- i 
rious feature in this disease, and bears strongly against the idea of I 
its being connected with any inflammatory condition of the tube. 
In the Hospital I^a Charite the treatment is routine ; it consists of : 
an emeto-purgative plan, which is continued day after day until i 
the symptoms yield. The purgatives we employ in the Meath 
Hospital is croton oil, combined with castor oil and mucilage, or 8 
given in the form of pill. When the bowels have been freely acted : 
on, the case generally goes on well. After the bowels have been \ 
opened, we continue the employment of the hip bath, the narcotic 
stupes, and anodyne injections, taking care at the same time to 
persevere in the use of purgatives. 

Andral makes a good remark on this point : — " Here (says he) 
are cases in which,, from some peculiar alteration in the state of 
innervation, the mucous surface of the bowels is rendered less sen- 
sible than in its ordinary condition, andean bear freely the stimulus 
of powerful purgatives. May not this condition also occur in other 
states of the economy 1 We are, therefore, led to conclude that 
purgatives are not, in all cases, direct stimulants. 

Painters' colic has been treated in Paris by bleeding and leech- 
ing, but this has not been found so successful as the ordinary pur- 
gative plan. I have never seen a case in which general bleeding 
seemed to be called for except one, and this was a most violent 
case which had resisted the ordinary means of treatment forty- 
eis;ht hours. I recommended bleeding from its well known anti- 
spasmodic power ; a quantity of blood was taken, and soon after 
the purgatives began to act, and the patient got relief. With respect 
to leeches, I have employed them only in those cases which are 
accompanied with symptoms of fever and gastric irritation ; where 
there is quick pulse, hot skin, foul tongue, thirst, vomiting, and 
epigastric tenderness. In such cases I have applied leeches, but 
my experience of them is, that the relief afforded is by no means so 
great, or so decided, as in cases of intestinal inflammation, and it is 
a mode of treatment which I do not by any means rely upon for 
removing the disease.* 

* [In the cases of painters' colic which have fallen under my notice and care, I 
have found but little benefit from other means, unless the lancet had been freely 



PAINTERS' COLIC. 



237 



After the violent symptoms have been subdued, the next thing 
you have to consider is, whether there is any paralytic affection, 
and how this is to be treated. If the disease be severe or of consi- 
derable duration, you may look for paralysis of one or both of the 
upper extremities with a good deal of certainty. This part of the 
subject, I believe, more properly belongs to the consideration of 
nervous affections, but, as I have gone so far into the treatment of 

! painters' colic, I may as well give the whole together. The paraly- 
sis which follows this disease is different from that which is the 
result of apoplexy ; it is a neurosis of the passive kind, and to be 
treated as such. The patient, some time after the occurrence of the 
usual symptoms of colic from lead, begins to complain of weakness 
in his arm, he feels some difficulty in extending his fingers or 
raising his hand to his head, and then the symptoms become more 
marked. The arm and fore-arm become rapidly atrophied, the 
paralysis principally affects the extensors, while the flexors retain a 
considerable share of power, the fingers are bent, and: the arm hangs 

I by the side. Here the first thing you should do is to adopt the 
treatment recommended by Dr. Pemberton in his work on Abdomi- 
nal Diseases, namely, to apply a splint to the inside of the fore-arm 
and hand, so as to counteract the preponderating influence of the 
flexors. Apply a splint to the fore-arm, wrap it up in flannel, and 
make the patient keep it supported by a sling. In this way you 
establish a kind of balance between the antagonist- muscles, and 
place the extensors under favourable circumstances for bringing 

! about a cure. If the patient has both arms affected, which is 
sometimes the case, change the splint from one arm, to the other 
every second day, and continue this alteration until the cure is 
completed. 

You will next have recourse to the use of strychnine, one of the 
best remedies we possess in cases where the paralysis does not de- 
pend upon organic diseases of the brain. This is a remedy which 
is given with good effects even in cases of paralysis from apoplexy, 
where there is reason to suppose that absorption of the clot has taken 
place. In a case of apoplexy, it can be employed only after some 
time and where depletive measures have been sedulously put in 
force, but in a paralysis of this description you may begin with it 
at once. Commence with the exhibition of one-twelfth of a grain 
of strychnine two or three times a day, and go on increasing the 
dose gradually, until a grain, or even a grain and a half, is taken 
in the twenty-four hours. To insure the exact division of this 
powerful drug, you should direct a grain of it to be dissolved in a 
few drops of alcohol, and then made into pills of an equal size with 
crumb of bread or conserve of roses. In this way you will succeed 
in bringing back the lost power of the muscles of the fore-arm and 
restoring its nutritive functions. I may mention here, that the 

used. In one of the two last cases which I treated in this way, with the addition of 
cups on the abdomen, there has been no return of the disease for nearly seven years, 
although the person has been regularly engaged in his trade ever since. — B.J 

21* 



238 STOKES'S THEORY AND PRACTICE. 

atrophy of the paralysed limb, which occurs in this disease, cannot 
be accounted for by supposing that it is -produced by want of 
exercise ; the emaciation is so rapid (sometimes taking place in ten 
days or a fortnight) that we can only attribute it to some unknown 
lesion of innervation. 

If the use of strychnine be followed by severe muscular twitches, 
pain in the head, or convulsions, you must omit it for some time, 
and then, when these effects have completely subsided, it may be 
resumed if necessary. You should also bear in mind that this 
remedy is one of those medicines which have been termed accumu- 
lative, that is to say, a patient may be taking it for a considerable 
time without any perceptible symptom, and then its effects explode 
suddenly, the quantity which has been accumulating in the system 
manifesting itself at once by symptoms of great intensity. Here 
you omit it immediately, and with a view of relieving the existing 
symptoms, prescribe a draught, composed of camphor mixture, 
ammonia, and opium. This has generally the effect of calming 
the nervous excitement, and you will seldom have any more trouble 
on this account. En passant, I would advise you, whenever you 
employ strychnine in private practice, to inform your patient of the 
occurrence of such symptoms, and tell him that there is no cause 
for alarm. Instead of strychnine, some of the continental practi- 
tioners are in the habit of prescribing brucine, and it is stated with 
considerable advantage. I have tried it in two or three cases 
without much apparent benefit, and I am inclined to think that it 
is decidedly inferior to strychnine. In France, however, it has 1 
been very largely employed, and has the reputation of being a 
remedy of considerable value in the treatment of paralysis. It has 
one advantage at least over strychnine, it can be much more easily i 
divided and regulated, so far as respects the quantity given, as it \ 
is a much weaker preparation than strychnine, one grain of which I 
is equivalent to six grains of brucine. 

In addition to these measures, I have seen much benefit result 
from the application of blisters and frictions, with stimulating lini- | 
ments to the spine. It is also of importance to remove the clothes \ 
in which the patients have worked ; they are frequently charged | 
saturated with lead, and have a considerable tendency to keep up 
the disease.* I have often seen an attack of painters' colic reap- I 
pear so shortly after leaving hospital, and without any evident ex- : 
posure, that I could only attribute it to the circumstance of their is; 
garments being saturated with the lead. 

* [This precaution is a very proper one. To it should he added that of a regu- 
lar and careful ablution of the hands and face, and arms if they have been exposed, 
and a careful combing- of the head and cleaning of the nails, before every meal, 
and also a daily washing of the feet. The night clothes ought always to be different 
from those worn during the day. By these means, and temperate living, which 
implies abstinence from all intoxicating drinks, painters and glaziers may escape " 
for a term of years, if not for life, from an attack of painters' colic. 

As respects the general therapeutic course required in this disease, I have not 
found it to differ materially from that which I have followed in bilious colic, 
with the treatment of which the reader is already acquainted, p. 127-132. — B.] 1 



PAINTERS' COLIC. 



239 



In the foregoing plan of treatment there is nothing new ; it is, in 
fact, a routine practice, but it is one which is borne out by the 
results of pathology, and which, from long experience, I can 
strongly recommend, I may also remind you that the plan of 
treatment followed in the hospital of La Charite, which has more 
cases of this disease than any similar institution in Paris,, is com- 
pletely routine. 

Other metals besides lead, as, for instance, copper, produce effects 
somewhat analogous. Copper is said to produce salivation, colic, 
and vomiting. Brass-founders are liable to these symptoms, as 
also other persons employed in the manufacture of copper. I have 
not seen the disease, but it is said to be analogous to lead-poisoning, 
so far as colic is concerned ; in other respects the symptoms differ, 
The convulsions are not so violent, nor is the paralysis or coma 
so frequent ; there is often considerable fever, thirst, difficulty of 
- respiration, precordial anxiety, diarrhoea, and prostration of 
strength, so that it comes much nearer to ordinary intestinal inflam- 
mation with fever, than painters' colic. Yet it is a curious fact, 
that, notwithstanding all this array of symptoms so closely border- 
ing on inflammation, it has been found in Paris, where several cases 
of this disease have been seen, that it is amenable to the same 
treatment as painters' colic, and that, under, the use of purgatives, 
. the fever, thirst, diarrhoea, and tenesmus subside. 

Mercury, under certain circumstances, will produce a most 
extraordinary affection, on which I shall here make a few observa- 
tions. The disease is not of very frequent occurrence, but it is of 
importance in practice to be able to recognise and treat it properly. 
It is a proposition well known to almost every one, that many 
bad effects have resulted from the abuse of mercury; and I need 
not tell you how many persons are injured by the empirical 
employment of this potent drug on all occasions and in all consti- 
tutions. It is a common opinion that mercury acts principally on 
the capillary and absorbent systems, but there can be no doubt that 
it also acts upon the nerves, and that in a very remarkable manner. 
I have seen cases where the constant use of calomel has produced 
a marked derangement of the nervous system, manifested by great 
irritability, tremors, hysterical excitement, and hypochondriasis. 
You will see in the various works on Toxicology an account of the 
effects produced by mercury on persons employed in quicksilver 
mines, and on tradesmen, such as looking-glass manufacturers and 
others, who come in contact with mercury. I shall read for you 
the notes of a remarkable case of this kind, which was some time 
back under treatment in the Meath Hospital. It may be called a 
form of the paralysis agitans from the effects of mercury. Similar 
cases have been described. 

A man, aged forty-six, was admitted into one of our medical 
wards in October, 1833. He stated, that from the time he was 
eight years of age he had been employed in a looking-glass manu- 
factory, and that his occupation principally consisted in what is 



240 



STOKES'S THEORY AND PRACTICE. 



technically termed the silvering of mirrors. In this process the 
operator's right hand is repeatedly immersed in a vessel filled with 
mercury, while the left fixes a sheet of tin-foil, on which the metal 
is rubbed. Artizans while thus engaged are in the habit of using 
a muffle, which covers the mouth and nostrils. This the patient 
said he had never used, because he found that those who were in 
the habit of wearing it did not enjoy better health. For thirty 
years he continued to enjoy tolerable health, with the exception of 
some bleeding from the gums, with shooting pains and a sense of 
formication in various parts of the body, accompanied by a slight 
loss of power in the hands, which came on at various times, and 
was generally relieved by the use of ardent spirits. He had been 
frequently salivated, and when admitted had lost nearly all his 
teeth. The mode in which he lost them was this: gum-boils formed 
close to the roots of the teeth, which soon after dropped out, and 
in this way the local inflammation subsided. About three years 
ago, he had an attack similar to that for which he had been admit- 
ted ; he went into the hospital and was put under an active anti- 
phlogistic treatment with relief. From that time up to the period 
of his admission, he had enjoyed tolerable health, except that the 
sight of the right eye was considerably impaired, and that his 
memory was slightly affected. He forgot the names of persons 
and places, and was frequently at a loss in endeavouring to recol- 
lect the persons to whom he had lent his tools. On being brought 
into the hospital he presented an extraordinary specimen of human 
suffering, and I was at first unable to give his complaint a name, 
the case being the first of the kind I had seen. It exhibited the 
phenomena of a violent spasmodic affection ; it was different from 
tetanus, or hydrophobia, or hysteria, but it bore some faint analogy 
to chorea. The head, arms, and fingers, particularly on the left 
side presented a succession of quick, convulsive, jerking motions. 
The angles of the mouth were retracted, the eyebrows twitching, 
the head constantly thrown back, but the agitation scarcely raised 
the arms. The nostrils were spasmodically dilated. The sterno- 
mastoid, trapezius, scaleni, diaphragm, and the abdominal muscles 
were similarly affected. Their contractions were short, rapid, and 
painful. From the constant hiccup with which the spasms of the 
diaphragm were attended, and the jerking motions of the tongue, 
his speech was interrupted and indistinct. He was occasionally free 
from spasms altogether, but whenever he transmitted volition to any 
part of the muscular system, it became instantly affected. When 
he endeavoured to raise his foot from the ground, it quivered and 
fell quite powerless and useless. Whenever he attempted to carry 
a vessel to his lips he generally overshot the mark, carrying the 
vessel towards his ear, nose, or forehead, and spilling its contents 
over his face or neck, so that it was a common saying among the 
patients in the wards, that he did not know the way to his mouth. 
But if the vessel was applied to his lips by another person, he could 
swallow easily. A sudden blast of cold air, the application of a 



DISEASES OF THE NERVOUS SYSTEM. 



241 



cold hand to the skin, or the abrupt entrance of any person iuto the 
wards brought on an attack of spasms. The muscles of the left 
| hand and of the left side were affected much more than those of 
the right. The mental powers were not impaired, the patient was 
intelligent, and seemed anxious to communicate the particulars 
J of his case. During the whole course of the disease he retained a 
' fulb power over the urinary discharge and defecation. There was 
| some slight tenderness on pressure over the fourth and fifth dorsal 
j vertebras, but the rest of the spine exhibited no increase of sensi- 
| bility. His skin was cool and dry, his pulse quick, weak, and 
' small, his bowels inclined to be costive, but easily moved by laxa- 
I tives. Here we see a marked difference between this affection and 
| painters' colic. 

The treatment adopted in this case was very simple. Leeches 
' were applied to the tender part of the spine, the patient was placed 
1 in a warm bath, and got some laxative medicine, followed by 
! an opiate. He was also ordered to have a large flannel shirt, and 
; to be placed in a warm, comfortable bed. He passed the night 
1 tolerably well, and next day appeared to be much improved. I 
shall not continue the daily reports of this case, but shall merely 
mention, that after a few days a great improvement took place. 
The spasms of the left side continued, though much less severe. 
Those of the purely voluntary muscles on the right ceased, while 
the spasms continued in the respiratory muscles on this side. We 
found that all the muscles of the face which have been called 
I respiratory by Sir C. Bell, the platysma, scaleni, pectoral, and 
; intercostal muscles, and the diaphragm, were thrown into violent 
spasms, while the purely voluntary muscles remained in a state 
of perfect quiescence. I am not aware that this circumstance has 
been observed in any other case. As far as it goes, it tends to 
corroborate the views of Sir C. Bell. In the treatment of this case 
we employed narcotic frictions, particularly those composed of 
the extract of belladonna to the spine, with considerable benefit. 
The patient was cured by very simple means, and at little expense 
to his constitution. 

— . . 

LECTURE XXIII. 

Diseases of the nervous system — Pathology of, unknown — Molecular change in the 
nervous centres — Difficulties of distinguishing arachnitis from encephalitis — Gene- 
ral and partial cerebritis — Symptomatology of — Diagnosis of — Preservation of intel- 
I lect in — Production of general symptoms by local lesion. 

I 

j To-day we commence the consideration of the diseases of the 
I nervous system, and here let me remark, that, even on the very 
| threshold, we have to encounter several difficulties ; some depend- 
ing upon the great obscurity of the symptoms — some upon the 



242 



STOKES'S THEORY AND PRACTICE. 



want of correspondence between the symptoms and known organic 
changes, and some upon the necessarily imperfect nature of our 
classification of nervous affections. Many persons are in the habit 
of taking a limited view of the nervous system. They suppose 
that, when we speak of its diseases, we merely allude to affections 
of the brain and spinal cord; but the truth is that the nervous sys- 
tem, so far as regards organization, is universal ; and there is evi- 
dence to show that, even in parts and tissues which present no 
appearance of nerves or nervous communication, there resides a 
nervous power, either inherent in their organization or derived 
from external sources, and by the latter mode, of nervous irradia- 
tion from surrounding tissues, has the sensibility of serous mem- 
branes been supposed capable of explanation. But there can be 
little doubt that even these tissues present nervous expansions, 
though of an infinite delicacy. They are, we know, supplied with 
white vessels, and doubtless have nerves corresponding to their 
vessels in size and function — nerves, insensible to us in health, but, 
when inflammation elevates the organ in the scale, capable of 
transmitting the most exquisite pain to the centre of perception. It 
seems, also, to be highly probable that nervous disease may com- 
mence not only in an affection of the brain or spinal marrow, but 
also in a similar condition of any part of the system. Again, if 
we admit the nervous system to be the governing and directing 
portion of the whole body, it is likely that some modification of 
that government precedes the alterations which take place in the 
circulatory and nutritive functions of other parts. Thus, in all 
diseases it may be laid down as a general rule, that there is an 
affection of the nervous system, either local or general ; or, in other 
words, that there is no disease which we could name, which does 
not present signs of an affection of the nervous system, either quoad 
the suffering organ itself, or of an affection more general and dif- 
fused. If we take, for instance, a case of gastritis or hepatitis, we 
find a lesion of function in the nerves of the respective organs, 
which, in certain cases, seems local ; but, if the inflammation be 
intense and the fever high, we have superadded to this a sympa- 
thetic affection of the brain or spinal cord. The same thing applies 
to all forms of local disease ; for in all there is an affection of the 
nerves, either confined to the suffering organ, or extending to the 
whole system. 

In reviewing the phenomena of nervous diseases, we find them 
presenting several varieties depending upon certain circumstances. 
In the first place, they vary according to the seat of the disease. 
We find that the signs and symptoms of affections of the cerebro- 
spinal system differ very considerably from those which character- 
ize diseases of the sympathetic nerves. Again, if we take any 
part of the nervous system, and examine its diseases, we find that 
here also there is a source of variation connected with the peculiar 
part affected. Thus, if we take the cerebro-spinal system, we find 
that disease of one part of it differs most essentially in symptoms 



DISEASES OF THE NERVOUS SYSTEM. 243 



from disease of another: we may have enormous and fatal disease 
of the spine without the slightest injury of the intellectual powers, 
I but we seldom have disease of the brain, particularly of the surface, 
; without a more or less appreciable lesion of the phenomena of the 
mind. To follow up this point, suppose we take the diseases of the 
i brain itself, as compared with each other ; we find that their symp- 
! toms vary according to the locality, so that, whether we look to 
j physiology or pathology, we must consider the brain as consisting 
| of several distinct parts, and not as an inseparable whole. It is 
j admitted, by many writers of high authority, that there is a differ 
I ence between the symptoms of disease affecting the periphery, and 
, disease affecting the central parts of the brain ; and there is reason 
! to believe that we may be able, in many cases, to diagnosticate 
affections not only of the centre and periphery of the cerebrum, but 
even of other parts of the organ. 

The same variety occurs with respect to the effects of diseases 
of the nervous centres. In some instances we have, as the result 
i of disease of the brain, a loss of muscular power, or of sensation, 
in different parts of the body — sometimes affecting the face, some- 
! times one side, or even both ; and these paralyses may be single or 
variously combined. It appears, then, that the component parts of 
i the nervous system, by being to a certain extent separate and dis- 
tinct, furnish a very extensive source of variety in the phenomena 
of nervous affections. 

Lastly, we have the varieties which depend upon the nature of 
| the lesion. We generally observe an obvious difference between 
cases of nervous disease, accompanied by some known change in 
the injured part, and cases in which no such change can be demon- 
strated. Thus, for instance, we know the symptoms of apoplexy, 
and that, in the majority of cases, it is a disease connected with 
some perceptible change in the circulation of the brain — as exces- 
sive distension of its vessels, or an effusion of blood on its surface 
or into its substance. We also have some idea of the nature of 
inflammation of the brain ; we know that its substance becomes at 
first red, then begins to soften, and finally is converted into a pulpy 
mass. Now, there are a number of symptoms which are so often 
and so constantly connected with peculiar organic changes, that, 
| the symptoms being known, we can make a tolerably correct guess 
at the nature of the alteration, or vice versa. 

On the other hand, however, we have a large a-n4 important 
catalogue of nervous affections, in which the symptoms give but 
very unsatisfactory information as to the real nature of the disease, 
and to the elucidation of which the painful and long-continued 
j investigations of the pathological anatomist have hitherto been 
, directed in vain. Of the actual nature of a numerous, complex, 
! and interesting class of diseases — the neuroses — we know nothing, 
j All we can say of them is, that they are examples of lesions of 
j function in various parts of the nervous system, presenting no trace 
of structural alteration appreciable by our senses. It is a startling 



244 



STOKES'S THEORY AND PRACTICE. 



fact, and one which must be a source of gloomy reflection to the 
pathologist, that many of the diseases of the nervous system, which 
present the most violent symptoms, are those in which there is the 
least perceptible organic alteration. Every man who has seen a 
case of hydrophobia, or tetanus, or mania, or epilepsy, has witnessed 
a train of extraordinary and horrible symptoms, infinitely worse 
than those which are seen to accompany even great organic altera- 
tions of the brain. 

Here, then, is a singular fact: that there is a part of the system 
presenting a series of diseases under this extraordinary law, that 
the most violent and frequently fatal symptoms are accompanied by 
the least perceptible organic alteration. Now, what is the nature of 
these neuroses'? To give you a familiar illustration, let us take a 
case of tetanus or hydrophobia as an example. Here we have a 
train of symptoms exhibiting the most frightful irritation of the ] 
nervous system ; and yet, when we come after death to examine, 
with eager curiosity, the cause of all these appalling phenomena, 
what do we find 1 — nothing. There is no unequivocal, no constant, 
no prominent alteration of any part of the nervous system, to throw 
light upon the obscurity of our opinions, and enable us to fix the 
nature or locality of the disease. We lay aside the knife in despair, s 
and bitter indeed is the consciousness of our ignorance. 

Two opinions have been entertained by pathologists with respect 
to those singular affections : one, that they are examples of some * 
peculiar modification of the nervous influence, independent of any 
organic change. In other words, the pathologists who entertain 
this opinion hold, that the principle of life may be altered in its 
phenomena, and admit of modifications, independent of any mole- 
cular change. The supporters of this doctrine reason thus : — In 
the phenomena of neuroses we have a train of extraordinary and 
violent symptoms unconnected with organic change. Now, it is • 
quite unphilosophical to say that there is organic change when we 
cannot see or demonstrate it ; and, on the other hand, it is not 
absurd to suppose that we may have lesions or peculiar modifica- I 
tions of the nervous principle, without any organic alteration. The - 
other opinion is, that in the neuroses there is some organic change, 
the nature of which cannot be ascertained, in consequence of our • 
limited powers of detecting elementary changes. In whatever light 
we view this question, it appears to be surrounded w ? ith difficulties. ■' 
No one can deny that neuroses are very different from organic I 
diseases of parts. If we compare them with that class which is most ; 
familiar to us — the inflammatory affections — we find a remarkable 
difference. In the first place, the neuroses may be brought on by 
causes not reckoned among those commonly capable of exciting 
inflammation. In the next place, their invasion is sudden, and 
their progress rapid ; they arrive at their acme in a very short 
period of time, and subside rapidly. These are characters which 
do not belong to the ordinary forms of organic disease. Again, we 
often observe the utmost intensity of nervous pain without the co- 
existence of swelling, redness, or heat of the part affected. We J 



DISEASES OF THE NERVOUS SYSTEM. 



245 



find, too, that they are not to be subdued by the antiphlogistic plan; 
on the contrary, several of them are either relieved or cured by an 
exactly opposite line of practice; and many cases, which would 
appear to demand the lancet, are known by long experience to be 
j most benefited by stimulants. Lastly, the most accurate and well 
conducted investigations of pathological anatomy have failed in 
| demonstrating the slightest organic change in these cases — at least, 
where changes are found, these are neither constant, competent, 
nor commensurate luith symptoms ; so that, whether we compare 
the information we derive from symptoms, or the result of patholo- 
I gical anatomy, we find a great difference between neuroses and 
organic diseases. It may be said that, though they are not inflam- 
matory affections, they have some resemblance to them. This, 
however, is only a gratuitous supposition; for, even in the very 
worst cases, they present nothing analogous to the results of inflam- 
i mation, and the brain and spinal cord are as free from perceptible 
organic change, in the majority of cases of fatal tetanus and hydro- 
phobia, as they would be in nervous affections of a slight and tran- 
! sient character. 

You must have been already convinced that it is difficult to form 
any clear or definite notion of the nature of neuroses ; indeed, the 
only thing we can say of them is, what they are not. When we 
reflect on nervous phenomena, and consider how occult, how mys- 
terious the properties of those organs which give rise to them are, 
j we are struck with astonishment at the discrepancy between cause 
i and effect. No medical man has ever witnessed a case of confirmed 
tetanus or hydrophobia, without being oppressed with a conviction 
of the imperfect and limited state of our knowledge of nervous 
| disease. 

It maybe very possible, that in these neuroses the change, though 
so slight as to escape our means of detection, does absolutely occur ; 
and yet such is the nature of nervous phenomena, that we must 
admit that great and extraordinary effects are produced by very 
slight causes. Do we see anything like this in nature? — any 
remarkable alterations in properties depending upon apparently 
slight causes ? We do — we see extraordinary changes taking place 
in the characters of various inorganic substances, (to which I need 
not particularly allude,) and there is no reason why the same thing 
! should not occur in organic structures. On considering the doc- 
trine of Isomerism, I should be inclined to think that it throws 
some light on this obscure subject. In chemistry, it is a well- 
known though singular law, that the properties of two bodies may 
be essentially different at the same time that their respective com- 
ponent elements are, as far as our knowledge goes, identically the 
same ; and the change, whatever it may be, appears to result, not 
from the abstraction or removal of any of the component atoms, 
but from their peculiar juxta-position. Now, it being admitted in 
chemistry that many bodies having the same constitution possess 
totally different properties, and this difference being explained by 

22 



246 



STOKES'S THEORY AND PRACTICE. 



the different position of their elements, it does not seem strange if 
the same thing should take place in the phenomena of organized v 
beings ; and, if this be the case, we have a key towards elucidat- f 
ing the nature of these neuroses, and can conceive how an analo- f 
gous change — a difference in the arrangement of the molecules of f 
the component parts of the nerves, or their centres — may produce ! ! 
new modifications of their properties, without making any distinct f 
change in their nature, or adding or abstracting a single organic f 
molecule. I am much inclined to adopt the opinion of those who j 
think that, in the neuroses, a peculiar organic change actually } 
takes place, though we cannot demonstrate its existence ; because, ; 
to reason on the phenomena of animal life, independently of 
organization, is to plunge blindly into hypothesis, and retrace the 
errors of an antiquated and exploded school. ^ 

In treating of the disease of the nervous system, I regret that 
time will not permit me to enter into the subject as fully as I could ; 
wish ; all that I hope to be able to accomplish is, to give a sketch 
of some of the more prominent affections. The arrangement I 
purpose to adopt is the following: — 1st, I shall treat of local : 
inflammations of the brain ; 2d, of general inflammations of that ; 
organ; 3d, of mere sanguineous congestion of hypersemia of the 
brain ; 4th, of apoplexy ; and 5th, of the various forms of paralysis. 5 
In taking up the subject of cerebral inflammation, I beg leave to ; 
observe, in limine, that the brain may be attacked by general or 
local inflammation ; and further, that it may, as stated in books, be 
inflamed in its membranes or in its substance, or in both together. 
A great deal has been written to show that we can distinguish, 
during life, between inflammation of the substance and of the mem- 1 
branes of the brain. On this point, I believe, we may come to this 
conclusion — that inflammation of the membranes of the brain, or 
arachnitis, may be distinguished from some cases of local inflam- 
mation of the cerebral substance, but that it cannot, in the present 
state of our knowledge, be distinguished from general inflammation !| 
of the brain. We can, in most instances, make a distinction be- f 
tween local disease of the brain and arachnitis ; but, when the whole 
substance of that organ is affected, our means of diagnosis fail. | 
This, however, is not so much to be regretted, as the distinction is !' 
of very little consequence, so far as treatment is concerned. Here 
we arrive at the knowledge of a principle highly consolatory in the 
practice of medicine; namely, that in many acute cases where the j 
diagnosis between two diseases of neighbouring parts is difficult or I 1 
impossible, it is also, so far as regards immediate treatment, unne- 
cessary. 

If we inquire what are the symptoms of membranous inflamma- 
tion of the brain, as laid down in books, we shall find them to be 
the following: pain, delirium, convulsions, alteration of sensibility, 
and coma. These are the symptoms which are generally given as 
characteristic of arachnitis; and it is quite true that they are 
observed in many cases of the kind. But the person must be dull ; 

\ 



I 



DISEASES OF THE NERVOUS SYSTEM. 



247 



indeed who thinks that such symptoms imply nothing more than 
; an inflammatory affection of the membranes of the brain. Take, 
for instance, one of the most prominent symptoms — delirium ; what 
; does this imply ? — that the portion of the brain which discharges 
the functions of intelligence or mind has been injured, and is ren- 
I dered incapable of performing its office. No one will venture to 
assert that the membranes of the brain are the organs of thought, 
i and that the delirium proceeds from their morbid condition : such 
a notion as this could not be entertained for a moment. What then 
| are we to suppose 1 One of these two things — either that there 
must be inflammation of the substance as well as of the membranes, 
or that the substance of the brain must be affected in a neurotic 
manner without any actual inflammation. As far as delirium is 
; concerned, it appears to me to be quite impossible to distinguish 
j between inflammation of the brain generally, and of its membranes. 
; The same rule applies to the other symptoms — convulsions, altera- 
tion of sensibility, and coma. I repeat, that all we can say on this 
| subject is, that, in such cases, there is either inflammation of the 
i substance as well as the membranes of the brain, or that, with the 
membranous inflammation, there is a neurotic condition of the sub- 
stance of the brain. Yet who, in such cases, can affirm with cer- 
tainty that the symptoms of derangement of the substance of the 
brain are merely neurotic, when inflammation is admitted to exist 
within the cranium, and when we know that the two inflammations 
! commonly co-exist? 

The fact of delirium occurring so frequently in inflammation of 
the membranes of the brain, is of considerable importance, as show- 
ing, not that membranes of the brain have anything to do with 
intelligence, but as supporting the opinions of those who believe 
the periphery of the brain to be the seat of the intellectual facul- 
ties ; and here is a fact which, as far as it goes, is in favour of the 
doctrines of phrenology. If we compare those cases of cerebral 
disease, in which there is delirium, with those in which it does not 
occur, we shall find that it is most common in cases where disease 
attacks the periphery of the brain, as in arachnitis. The cases in 
which we observe great lesions of the brain without delirium are 
generally cases of deep-seated inflammation of a local nature, or 
inflammation of those portions of the brain which the phrenologists 
consider not to be subservient to the production of mental pheno- 
mena. This fact, also, would seem to confirm the truth of the 
opinion of the difference in function between the medullary and 
cortical parts of the brain. It is supposed that the cortical part of 
■ the brain is the organ of intelligence, while the medullary portion 
I performs a different function. It is, however, a curious fact, that 
I in delirium the inflammation is generally confined to the surface of 
the brain, and that, in cases of deep-seated inflammation, the most 
important symptoms are those which are derived from the sym- 
pathetic affections of the muscular system. 

Partial encephalitis may be either primary or secondary. An 



i 



248 



STOKES'S THEORY AND PRACTICE. 



example of the latter is that inflammation of the substance of the 
brain which supervenes on apoplectic effusion, tumours, or cancer. 
What we generally observe, in a case of this kind, is more an alter- 
ation in the functions of the muscular system, and less of the intel- 
lect. This alteration consists at first in an apparent increase of 
innervation in certain muscles of the body, and we generally find 
that one of the earliest symptoms of local encephalitis is the occur- 
rence of pain in some of the muscles of the extremities. This is a 
curious fact, but one which is well established. In partial ence- 
phalitis there is often but little, or even no pain in the head ; and 
the only warning we have of the approach of cerebral disease is 
the occurrence of pain in the extremities, followed by rigidity. 
Here are the two most prominent symptoms of the disease — pain in 
the muscles of the extremities, and then rigidity. Further, we have 
alternate spasms and relaxations of the muscles, in which, however, 
the power of the flexor muscles ultimately prevails ; so that, if the 
disease be in the fore-arm, it may become permanently flexed on 
the arm, and the contraction of the fingers is sometimes so great as 
to drive the nails into the flesh. If it affects the leg, the heel may 
be pressed against the buttock sometimes so forcibly as to form a 
sore. As the case proceeds, the limb becomes more fixed in its 
new position, and every attempt to extend it causes pain. During 
the prevalence of these symptoms, it frequently happens that the 
patient does not feel pain in the head, or any diminution of intellec- 
tual power. The absence of pain in the part affected may be ac- 
counted for by recollecting that it is a general law, that all inflam- 
matory affections of deep-seated parts are, to a certain extent, of a 
comparatively painless character ; and we may account for tho 
non-existence of any lesion of the mind, by remembering that the 
disease is partial, and confined to a portion of the brain which ap- 
pears to have little or no connection with the intellectual functions. 
In cases of this kind, when the muscles of the face are affected, the 
phenomena are interesting, from their being (in the first stage) the 
reverse of those of apoplexy. The face is drawn from the affected 
side, and the tongue pushed, by the opposite half of the genio-hyo- 
glossus muscle, to the affected side. This is the spastic stage, when 
complete disorganization has not yet occurred. But when this 
happens, then the phenomena of the face are like those of apoplexy, 
because the opposite muscles, which were in a spasmodic, are now 
in a paralysed state ; so that the face is drawn to the affected side, 
and the tongue pushed from it, by the healthy action of muscles 
which are deprived of their antagonists. 

I mentioned before that delirium may not occur during the course 
of a partial encephalitis ; and I gave, as a reason for this, the cir- 
cumstance of the disease being of small extent, and confined to 
parts of the brain which do not discharge any of the functions of 
mind. Another explanation has been given, drawn from the con- 
sideration of the double nature of the brain. It is thought that, 
where disease exists in one part of the brain, sanity may be still 



DISEASES OP THE NERVOUS SYSTEM. 249 



preserved in consequence of the healthy condition of the corres- 
ponding part ; but where disease attacks both hemispheres together, 
as in a case of arachnitis, then there is a distinct lesion of the men- 
tal faculties. 

The next stage of partial encephalitis is that in which the dis- 
eased portion of the brain breaks down, softens, and is converted 
into purulent matter. This stage is marked by a new train of 
symptoms. The first stage is characterized by pain occurring in 
the muscles of the face, or of the extremities of either side, and 
followed by great rigidity. The second stage is of a different cha- 
racter ; the rigidity and spasm of the muscles diminish, and are 
succeeded by a paralytic and flaccid state of these organs. Volun- 
tary motion on the affected side now becomes impossible, the organ 
on which it depends being destroyed. Now let us, for sake of 
arrangement, call the first, or spastic condition, the convulsive 
paralysis, and the second, the paralysis with resolution. In the 
first, or convulsive stage, the brain is affected in the first degree ; it 
is labouring under irritation or actual inflammation, and the disease 
still holds out a tolerably fair prospect of relief or cure. But in the 
second stage a cure is impossible, and hence it is a matter of the 
greatest importance to commence our operations at an early period ; 
and, by having recourse to prompt and active treatment, give the 
patient every chance for a cure. 

In the partial inflammation of the substance of the brain, sen* 
sation is variously altered. In some cases motion is lost, while 
sensation remains intact; in others, sensation is partially or wholly 
abolished. In many instances the intellectual powers remain in all 
their integrity, or but little impaired, even after the occurrence of 
symptoms which mark the softening down of the substance of the 
brain, and its conversion into purulent matter. In a few there is, 
during the first stage of the disease, a slight alteration in the state 
of the intellect, marked by a certain degree of excitement or exalta- 
tion of the mental faculties, and this, on the supervention of the 
second stage, is exchanged for a state of depression. In fact, the 
morbid phenomena of the mind and of the muscular system, where 
they co-exist, appear to be regulated by the same laws. Where the 
disease is extensive, you can easily observe the injury of the mental 
faculties which accompanies the second stage; the patient answers 
slowly when questioned ; his memory is weak, and his countenance 
has a stupid expression. But cases, even of extensive local sup- 
puration, have been described by various authors, in which there 
was no lesion of the intellectual functions observed. These, how- 
ever, generally admit of an explanation. Thus, in the cases recorded 
by Lallemand, the abscesses were situated in the cerebellum, pons 
Varolii, and other parts which are not supposed to have any connec- 
tion with the phenomena of mind. There are several well-authenti- 
cated cases of extensive disease, not only of these parts, but even 
of the substance of the hemispheres, occurring without any appre- 
ciable lesion of the intellect. Thus, Mr. O'Halloran gives the case 

22* 



250 STOKES'S THEORY AND PRACTICE. 



of a man, who, after an injury which destroyed a large portion of 
the frontal bone, had extensive suppuration of the brain, and lost an 
enormous quantity of the substance of one of the hemispheres, and 
yet preserved his intellect entire up to the moment of his dissolution, i 
There is some difficulty in explaining this. It is an opinion enter- | 
tained by some physiologists, that when one hemisphere is diseased 
its functions are discharged by the other; and that, the brain being 
a double organ, disease of one side does not impair the functions of i 
the other. But, in answer to this, it may be urged that there are 
many cases on record in which disease of a single hemisphere has 
produced great alterations of intellect. The supporters of the former I 
opinion attempt to explain such cases in this way. They state, 
that in the majority of such cases there was, besides the local ence- 
phalitis, inflammation of the arachnoid membrane, and that the i 
lesion of intellect w r as not so much the effect of local disease of the 
brain as the result of its complication with an arachnitis engaging 
the whole periphery of the organ. In the next place, they explain 
the fact of a general affection of the brain arising from local disease, J 
as depending in most cases on the pressure which the tumefied S 
state of the diseased portion necessarily makes on the sound hemi- : 
sphere ; and they state that this pressure must be very considerable, : 
as the brain, being confined within a bony cavity, has no power of 
expanding itself. Now, it is a most interesting fact, in support of 
this view, that, in a great number of the cases of loss of brain 
with preservation of intellect all through the case f an extensive 
opening existed in the bones of the skull, so as to permit of expan- f 
sion in the diseased hemisphere, and prevent the pressure being s 
exercised on the opposite one. This point appears to be borne out p 
by the result of Mr. O'Halloran's cases, and by many other exam- k 
pies. Lastly, in every acute case of local inflammation of the 
brain, two causes having a tendency to produce symptoms exist, b 
One of these is the local disease which gives rise to those pheno- 
mena of motion and sensation which we observe on the opposite f 
side of the body; the other is the determination of blood to the l 
whole brain, the result of the irritation of that disease.—-" Ubi stimv^ f 
lus ibi humorum qffluxus." ll 



LECTURE XXIV. 

Encephalitis, diagnosis of — Preservation of function with organic disease — Vicarious 
actions of parts— Importance of pathology to phrenology — Use of pathology to phre- 
nologists — Arachnitis at the base of the brain — Symptoms of — Influence of age over 
the intellectual faculties — Opinions of Bouillaud, Serres, and Foville — Influence of 
the optic thalami and corpus striatum on the motions of the extremities — Diagnosis 
of disease of the cerebellum — Connection with the generative system — Remarkable 
cases of* 

We were occupied at our last lecture in considering some of the 
phenomena of partial encephalitis, by which is generally meant, a 



ENCEPHALITIS. 



251 



localised inflammation of the deep-seated parts of the brain ; because 
superficial inflammation of the cerebral substance is very rarely 
j partial. I endeavoured to show that the diagnosis of this local 
| encephalitis was to be drawn, in a great measure, from the occur- 
j rence of pain and muscular affections of one side of the body ; in 
i other words, that the phenomena of this disease were partial, so as 
! to give us at once a distinction between general and partial inflam- 
I mation of the brain. In cases of general inflammation, we have 
I convulsions of both sides — delirium and coma ; in the partial form 
i these symptoms are absent until complication takes place. Thus 
! the supervention of delirium, or of convulsions on both sides, in a 
, case where previously the signs of only partial encephalitis existed, 
' would point out, in all probability, an extension of disease to the 
opposite hemisphere. I also endeavoured to point out the different 
modes in which partial encephalitis might be accompanied with 
I symptoms of a general character, or affecting both sides ; that 
there might be a co-existing inflammation of the membranes ; or 
that the pressure of the diseased on the healthy hemisphere of the 
brain might be the cause of the complication. I stated, that some 
of the most remarkable cases of extensive destruction of the brain, 
without perceptible injury of the mental powers, were those in which 
a traumatic opening in the skull gave full scope to the swollen parts, 
and obviated the effects of pressure on the sound hemisphere. I 
also observed that, in cases of local affections of the head, there are 
two causes which have a tendency to produce general symptoms. 
! One of these is the cause which determines the pain and muscular 
affection of the opposite side ; the other is the general determination 
of blood to the head ; so that we may have cases in which the 
actual inflammation is limited to a part of one hemisphere, and yet, 
from the general determination of blood to the head, we may have 
coma and general symptoms. 

To return again to the interesting consideration of great loss of 
cerebral substance with preservation of intellect, I have to remark, 
that this circumstance is one which some persons might quote 
against the opinion that the brain was the organ of intelligence ; 
and I believe this fact has been laid hold of by the opponents of 
phrenology, and put forward as a powerful argument against the 
I truth of its doctrines. Thus, for instance, in the case of Mr. 
O'Halloran's patient, who lost a large portion of one hemisphere, 
and yet, with all this mischief, the powers of the intellect remained 
unimpaired ; it would not seem strange if a person should say, here 
is vast destruction of substance without any lesion of intelligence; 
how then can the brain be considered as the organ of thought? 
But let us look at this matter in its true point of view. In the first 
place, it is to be remembered that cases like this are rare — that they 
are to be considered as the exception and not as the rule. I have 
already shown you, that it is a law in pathology that lesion of 
structure and lesion of function are not always commensurate. 
This law applies to the brain as well as to all the other organs. 



252 



STOKES'S THEORY AND PRACTICE. 



To say that the brain was not the organ of intelligence, because in 
cases of extensive cerebral disease that intelligence was preserved, 
is false reasoning. A man will digest with a cancerous stomach ; 
is it to be argued from this that the stomach is not the organ of 
digestion 1 I have seen the liver completely burrowed by abscesses, 
yet the gall-bladder was full of healthy bile. I have seen one lung 
completely obliterated, and yet the respirations only sixteen in the 
minute, and the face without Iividity. What do these facts prove? 
Not that the health of organs is of no consequence, but that with 
great disease there may be little injury of function. 

By reference to the original laws of organization, we may (in 
some cases at least) arrive at an explanation of this fact. You 
know that organs are primitively double ; and we find, that though 
the fusion at the median line is produced by development, yet that 
the symmetrical halves still, to a certain degree, preserve their 
individuality. Thus we see how the laws of organization affect 
the phenomena of disease, and recognise a provision, acting from ( 
the first moment of existence, against the accidents of far distant 
disease. 

Now, admitting that the brain is the organ of thought, we may 
suppose that, as in case of partial obstruction of the lung from 
inflammation, the remainder of the organ takes on an increased 
action, so as to supply the place of that which has been injured or 
destroyed. We know that if one lung be hepatised, the other takes 
on its functions, and carries on the process of respiration for a time. 
That this is the case, is shown, first, by life being continued, and, 
secondly, by the stethoscope, which informs us that the respiration 
of the lung, which has a double duty thrown upon it, is remarkably 
intense, proving the force of its action ; and it has been further 
established, that the lung which thus takes on a supplemental action . 
may become enlarged and hypertrophied. May not this also occur \ 
in the brain? There is no reason why such a pathological pheno- !. 
menon, occurring in one viscus, may not also take place in another. 
But the opponents of phrenology say, supposing the organ of causa- 
tion to be destroyed, how can the person continue to reason ? It ^ 
strikes me that the only way in which we can account for this is, j. 
by supposing that other parts of the brain take on the functions of I 
those which have been injured or destroyed. Nor is there any [ 
thing extraordinary or anomalous in such a supposition. We see, - 
almost every day, examples of this kind. We see that in certain [ 
diseased states of the liver, accompanied by suppression of its secre- ' 
tion, its functions are assumed by other parts, and bile continues to J 
be separated from the blood by the kidneys, salivary glands, and by I 
the cutaneous exhalants. Here is a remarkable case, in which the I 
glands and other parts take on the performance of a function totally | 
different from that in which they are ordinarily employed. We 1 
find, also, that when the urinary organs are obstructed, urine, or its I 
principles, are discovered in parts of the system where we should I 
not at all expect them. Thus we have a very remarkable case J 



ENCEPHALITIS. 



253 



j detailed in the American Journal of the Medical Sciences, in which 
we find that a young female, who laboured under paralysis of the 
I urinary organs, discharged urea from almost every part of the body, 
even from the ears. Neither is there anything very extraordinary 
in this. In several instances of suppression of the menstrual dis- 
charge, do we not see a vicarious secretion taking place from the 
surfaces of parts the most distant, and unconnected with the uterine 
! system? It is a well-established law, that when the functions of 
' organs are suspended or destroyed, other parts will often take on 
j the action of the injured vise us. Now, supposing that a portion of 
! the brain is to be looked upon as the organ of causation, and such 
j portion is injured or destroyed, there is no reason why the remain- 
ing sound portion of brain should not take on, at least to a certain 
extent, in addition to its own, the functions of that part which has 
been injured. If, independently of any phrenological views, we 
admit the brain. to be the organ of thought, there is no reason why 
we should not admit that the loss of intellectual power, produced by 
lesion of one part, may not be supplied by an increase of activity in 
the remaining portions. It is only by a supposition of this kind 
that we can account for the preservation of the integrity of mind in 
many cases of disease of the brain. If we admit the phrenological 
doctrines, we can suppose that when one organ is injured, another 
may take on an additional function, and in this way preserve the 
integrity of the intellect ; so that, whether we reason from phreno- 
logy or not, the continuance of soundness of mind, in cases of 
injury of the brain, can be understood when you come to contrast 
it with other analogous pathological facts. I again repeat, that it 
is not more extraordinary that, in case of local injury of the brain, 
the sound parts should lake on a supplemental action, than that bile 
should be eliminated by the salivary glands, skin, and kidneys, or 
that the principles of urine should be discharged from almost every 
part of the system, or that a vicarious discharge from the roots of 
the hair should supply the place of the uterine secretion. 

On this subject, one point should be always borne in mind, viz., 
that we may be wrong in saying that a patient is quite sane, while 
he is still an invalid and in bed. Unless we can show that after 
his recovery, and in his various intercourse with the world, he pre- 
serves his original intelligence, it w r ould be wrong to assert that 
there has been absolutely no lesion of intellect consequent on the 
affection of the brain. While lying at ease in bed, and unaffected 
by any moral stimuli, he may seem to possess a sound condition of 
mind ; he may put out his tongue, or stretch forth his hand, when 
requested ; he may give an accurate account of his symptoms, and 
answer all the ordinary medical interrogatories with precision. 
But you are not, from this, to conclude that he is perfectly sane. 
Many persons, under these circumstances, have died in bed, and 
appeared to preserve their intellect to the last ; but in such cases, 
the test of sanity, intercourse with the world, could not be fairly 
applied, and hence I think that there are not sufficient grounds to 



254 



STOKES'S THEORY AND PRACTICE. 



pronounce a decided opinion as to the real condition of the intellect 

in such cases. 

Before I quit this part of the subject, I wish to make a few 
remarks on the doctrines of phrenology. There can be no doubt 
that the principles of phrenology are founded on truth, and, of 
course, highly deserving of your attention, as likely, at some future 
period^when properly cultivated, to exercise a great influence over 
medical practice. The great error of the phrenologists of the pre- 
sent day, consists in throwing overboard the results of pathological 
anatomy. If a pathological fact is brought forward, as appearing 
to bear against the validity of their opinions, they immediately 
exclaim, " we dont recognise any fact or principle drawn from dis - 
ease; our science has to do with the healthy, and not the morbid, 
condition of the brain." Now, this is altogether absurd. Phreno- 
logy, if true, is nothing but the physiology of the brain, and patho- 
logy is nothing but the physiology of disease. Phrenology must 
be tested by disease as well as by health, and if it does not stand the 
test of pathology, it is wrong. If phrenology be a science founded 
on truth, if it is a true physiology of the brain, or of that portion of 
it connected with mental phenomena, one of two results should 
obtain — either that it should be confirmed by pathology, or that the 
difficulties, which pathology presents, should be explicable in a 
manner consistent with the science. The phrenologists, in my 
mind, are doing a direct injury to the cause of their science, by 
their unnecessary and ill-timed hostility to pathology. It is idle to 
say, as they do, that theirs is the science of health, and that it is 
unfair to apply to it the test of disease. From pathology is drawn 
a host of facts, from which the doctrines they profess derive their 
principal support. The mere phrenologist, who understands not 
and despises pathology, is nothing better than a charlatan, and pro- 
fesses a science which he does not comprehend. If he would recol- 
lect that the brain in a state of health is most, and in a state of 
disease least, adapted to the purposes of thought, he would see that 
this is one of the strongest arguments in favour of his doctrine, that 
the brain is the organ of mind. The more healthy it is, the fitter it 
is to discharge the functions of intellect, and vice versa ; yet phre- 
nologists are so absurd as to think that pathology has nothing to do 
with their science. 

But besides confirming the doctrine that the brain is the organ of 
thought, there are innumerable facts drawn from pathology, which 
have a tendency to prove that particular parts of the brain are the 
organs of peculiar phenomena. We see an injury on one part of 
the brain, accompanied by a train of symptoms indicating some 
peculiar lesion of mind; "we see an affection of another part, 
attended by a different class of phenomena. Here pathology, the 
science which phrenologists reject and despise, goes to establish the 
groundwork of their doctrines, that the brain consists of a congeries 
of parts, having each a separate and distinct function. We find, for 
instance, that disease of one portion of the brain affects the intellect ; 



ENCEPHALITIS. 



255 



of another, the generative organs; of a third, the muscular system. 
What does this prove but that the brain is not a simple organ, but 
composed of a congeries of parts, each of which governs a different 
part of the system, or ministers to a peculiar purpose? Now, what 
is this but what the phrenologists themselves wish to prove ? 

Further, the professors of phrenology have placed all their 
organs on the surface of the brain, and for this they have been 
loudly censured. Phrenology, it is urged, knows, or professes _to 
know, nothing about the central parts of the brain, which must be 
equally important with the superficial, and have confined their 
investigations to the surface alone. Now it is a curious fact, that 
the pathology which they deny, in this instance, furnishes the best 
reply to this objection. I mentioned at my- last lecture, that if we 
examine the symptom of delirium, we find that it characterizes the 
inflammation of the periphery, and is commonly wanting in that of 
the deep-seated portions. In other words, mental alienation is the 
characteristic of the disease of that portion of the brain where the 
phrenologists have placed the intellectual organs. Here is a strong 
fact in favour of the doctrines of phrenology, derived from that 
science which the mere phrenologist throws overboard and despises. 
Again, according to the researches of some celebrated French 
pathologists, there are a number of facts to show that there is a 
remarkable difference between the symptoms of arachnitis of the 
convexity and of the base of the brain. This conclusion, which, 
after a most careful series of investigations, was adopted by them, 
J is borne out by the results of my experience, and appears to me to 
be established on the basis of truth. They have discovered that 
arachnitis of the convexity of the brain is a disease characterized 
by prominent and violent symptoms, early and marked delirium, 
intense pain, watchfulness, and irritability. We have first delirium, 
pain, and sleeplessness, and then coma. But in arachnitis of the 
base of the brain, the symptoms are of a more latent and insidious 
character ; there is some pain, and the coma is profound, but there 
is often no delirium. What an important fact for the supporters of 
phrenology is this, and how strikingly does it prove their absurdity 
in rejecting the lights derived from pathology ? Here we find the 
remarkable fact, that inflammation of the arachnoid, investing the 
base of the brain to which the phrenologists attach, comparatively, 
no importance, is commonly unattended with any lesion of the 
intellectual powers, while the same inflammation of the convexity 
is almost constantly accompanied by symptoms of distinct mental 
alienation. 

It is objected to the phrenologists that they know little or nothing 
j of the central parts of the brain ; that though these parts may be 
j fairly considered to be of as much importance as any others, still 
! they do not admit them to be organs of intellect. Now what does 
j pathology teach on this subject ? It shows that we may have most 
i extensive local disease of the central parts of the brain — that we 
j may have inflammation, suppuration, abscess, and apoplexy, with- 

i 



256 



STOKES'S THEORY AND PRACTICE. 



out the slightest trace of delirium. Indeed there can be no doubt 
that the central portions of the brain have functions very different 
from those on the surface. They appear more connected with 
another function of animal life, muscular motion and sensation. 
Then let us examine the phenomena of old age. Every one is 
familiar with the fact, that when a man arrives at an extreme age, 
he generally experiences a marked decay of intellectual power, and 
falls into a state of second childhood. Does pathology throw any 
light upon this circumstance ? It does. From a series of ingenious 
and accurate investigations, conducted by two continental patholo- 
gists, Cauzevielh and Desmoulins, it has been found that a kind of 
atrophy of the brain takes place in very old persons. According to 
the researches of Desmoulins, it appears that, in persons who have 
passed the age of seventy, the specific gravity of the brain becomes 
from a twentieth to a fifteenth less than that of the adult. It has 
also been proved that this atrophy of the brain is connected with 
old age, and not, as it might be thought, with general emaciation of 
the body ; for in cases of chronic emaciation-from disease in adults, 
the brain is the last part which is found to atrophy ; and it has been 
suggested that this may explain the continuance of mental powers, 
during the ravages of chronic disease ; and also the nervous irrita- 
bility of patients after acute diseases, in which emaciation has taken 
place. 

I might bring forward many other facts to show that phrenology 
is indebted to pathology for some of the strongest arguments in its 
favour: and I think that those phrenologists who neglect its study, 
or deny its applicability, are doing a serious injury to the doctrines 
they seek to establish. The misfortune is, that very few medical 
men have turned their attention to the subject ; and that with few 
exceptions, its supporters and teachers have been persons possess- 
ing scarcely any physiological, and no pathological, knowledge. 
Phrenology will never be established as a science until it gets into 
hands of scientific medical men, who, to a profound knowledge of 
physiology, have added all the light derived from pathological 
research. To give you an instance of the mode of reasoning of 
the non-medical phrenologists. In their drawing-room exhibitions, 
they appeal with triumph to the different forms of the skull in the 
carnivorous and graminivorous animals, with respect to the develop- 
ment of destructiveness ; and all are horrified at the bump on the 
tiger's skull. But, as Sir H. Davy well -observes, this very protu- 
berance is a part of the general apparatus of the jaw, which requires 
a more powerful insertion for its muscles in all beasts of prey. 
Phrenology, as generally taught, may answer well for the class of 
dilettantis and blue-stockings, or for the purposes of humbug and 
flattery; but its parent was anatomy, its nurse physiology, and its 
perfection must be sought for in medicine. The mass of inconse- 
quential reasoning, of special pleading, and of "false facts" with 
which its professors have encumbered it, must be swept away, and 
we shall then, I have no doubt, recognise it as the greatest discovery 



ENCEPHALITIS. 



257 



J in the science of the moral and physical nature of man that has 
ever been made. I feel happy, however, in thinking that, of late, 
the science has been taken up on its true grounds, in Paris, London, 
and Dublin. Vimont's splendid work on Comparative Phrenology 
will form an era in the science. In London, Dr. Elliotson has di- 
rected the energies of his powerful mind to the subject ; and in 
! Dublin we have a Phrenological Society, of which Dr. Marsh is 
j the president, and my colleague, Dr. Evanson, the secretary; and 
\ under such auspices, much is to be expected.*' 

Having drawn your attention to the ordinary symptoms of local 
encephalitis, our next inquiry is, how far we can diagnosticate the 
actual seat of disease from phenomena observed during the life of 
the patient. Do not suppose, for a moment, that this part of the 
subject is undeserving of your attention, in the strongest sense of 
the word. Recollect that the more accurate and extensive is diag- 
! nosis, the more certain and available is the practice of medicine. 
On this subject, matters are not altered to the same extent as in the 
cases of chest or abdominal diseases. In our knowledge of the two 
latter, we have made vast strides within the last few years; but in 
! cerebral affections, though much has been affected, much still 
remains to be done ; and it is not improbable that some of the 
opinions on this subject, still promulgated in schools, require 
correction. If we examine the various cases of cerebral disease on 
record, we find that in some the paralysis was complete, and that 
sensation and muscular motion became, as it were, annihilated. In 
! other cases, the muscular system alone appeared to suffer ; while in 
a third class we find that sensibility is destroyed, while the power 
of motion remains intact. Again, in some we have complete 
hemiplegia, in others the paralysis is but partial ; in some the affec- 
tion is slight and transient, in others it is incurable and permanent. 
The result of all this would appear to imply that there are different 
states and seats of cerebral disease, producing different modifications 
of nervous phenomena. It has been taught, that a paralysis of the 
organs of speech points out a lesion of the anterior lobes of the 
brain, and there are many cases on record in support of this 
-opinion. Here is a pathological statement strongly in favour of the 

* [As a valuable contribution to the science of anthrophology, the great work, 
Crania Americana, by Dr. Samuel George Morton, deserves special notice and 
consideration. Though not prepared in the spirit, it furnishes important illustra- 
tions of phrenology. The author, in his dedicatory epistle to Mr. John S. Phillips, 
says: — "You and I have long admitted the fundamental principles of phrenology, 
viz., that the brain is the organ of the mind, and that its different parts perform 
different functions ; but we have been slow to acknowledge the details of cra- 
nioscopy, as taught by Doctor Gall, and supported and extended by subsequent 
observers. We have not, however, neglected this branch of inquiry, but have 
endeavoured to examine it in connexion with numerous facts, which can only be 
fully appreciated when they come to be compared with similar measurements 
derived from the other races of men. Yet I am free to acknowledge that there is 
a singular harmony between the mental character of the Indian and his cranial 
developments as explained by phrenology." — B.] 

23 



258 



STOKES'S THEORY AND PRACTICE. 



doctrines of phrenology. But, on the other hand, it must be con- 
fessed that there are numerous cases on record of lesion of the 
powers of speech, independent of any affection of the anterior lobe ; 
and hence, as far as the diagnosis of lesion of the anterior lobe, 
derived from loss of speech, is concerned, we cannot make up our 
minds. You are aware that the phrenologists place the organ of 
language in the anterior inferior part of the brain. Now, when an 
affection of this portion of the brain is found to coincide with the 
loss of speech, it is all very well ; but the difficulty is to account 
for those cases of loss of speech in which there is no appreciable 
lesion of the substance of the anterior lobe. In investigation on 
this point, however, you must bear the following distinction care- 
fully in mind. The organ of language of the phrenologists is not 
properly the organ of the power of speech, but that by which, as it 
were, thought is converted into language. A man, from paralysis 
of his tongue, might be incapable of speaking; and such a case, 
existing without lesion of the anterior lobes, might be most unfairly 
quoted against the phrenologists.* Again, paralysis of the upper 



* [A very interesting discussion on this subject was quite recently 
held at a meeting of the French Royal Academy of Medicine. M. 
Bouillaud, in a memoir communicated fifteen years ago, had col- 
lected the details of sixty-four cases, to show that the phrenological 
organ of language is seated in that portion of the anterior lobes of 
the cerebrum which rests on the roof of the orbits, as first an- 
nounced by Gall, and subsequently confirmed by the observations of 
Spurzheim and others. On the present occasion M. Bouillaud added 
the reports of thirteen other cases, which have come under his notice, 
and all of which, he thinks, tend to prove the correctness of the 
phrenological doctrine. He admits that several instances appa- 
rently opposed to this doctrine, have been published by MM. Cruveil- 
hier, Andral, Lallemand, and others ; but he insists that the details 
of these cases have always been unsatisfactory, and never suffi- 
ciently complete for the purposes of an absolute decision. 

MM. Richoux and Cruveilhier followed in opposition to M. 
Bouillaud, introducing, among other objections, that one, the fallacy 
of which has been pointed out by Dr. Stokes in the text — when he 
states : " The organ of language of the phrenologists is not properly 
the organ of the power of speech, but that by which, as it were, 
thought is converted into language." The phrenological faculty of 
language is certainly not the same as the faculty of speech or ar- 
ticulation. One is the memory of words ; the other is the mere 
power of expressing or enouncing them. 

M. Blandin advocated the opinion of M. Bouillaud and the 
phrenologists, and, in confirmation of them, related the following 
case : — 

" A child received a musket-ball in the orbit ; after destroying 
the eye it traversed the exterior orbitar plate, and made its escape 



ENCEPHALITIS. 



259 



extremities has been connected with disease of the optic thalami, 
and posterior lobes of the brain. It is the opinion of Bouillaud, 
Serres, and others, that the optic thalami regulate the motions of 

just in front of the ear. This child, whom I saw at the Hotel-Dieu 
several weeks after the accident, had lost all power of articulation. 
During its recovery, it was necessary to teach and accustom it to 
pronounce words. When it left the hospital, it was able to articu- 
late its own name, and a few other words. Now in this case is it 
not highly probable that the superior orbitar plate was fractured, 
and that an inflammatory process had extended to the point of the 
anterior lobe which rests upon it 1 

" As to the objected cases, in which the lesion of other parts of 
the brain seemed to occasion a loss or some disturbance of speech, 
they prove nothing in my opinion against the opinion of M. Bouil- 
laud ; for the corpus striatum and the thalami optici, for example, 
contribute by their irradiations to the formation of the anterior 
J lobes ; and the same may perhaps be said of the fibres of the upper ■ 
i part of the medulla spinalis, which are in truth the primary roots 
of these parts. 

" On the other hand, even if it can be shown that in some cases, 
where there has been disease of the anterior lobes, the speech has 
not suffered, it may possibly be that the immediate seat du prin- 
cipe coordinateur was not involved in the lesion. M. Bouillaud 
, has not affirmed that the whole of the anterior lobe presides over 
the faculty of language ; a small portion of it only being, according 
! to the phrenological views, the seat of this power. 

" M. Martin Solon adduced the following cases from his own 
practise in confirmation of the same doctrine. 

1. " A girl had been for a length of time affected with slight im- 
pediment in her speech ; gradually she lost the power of uttering 
even a syllable, and every movement of the tongue was lost. 
Symptoms of contraction and spasm came on, and she died. On 
dissection, besides the usual traces of chronic meningitis, several 
hydatids were found in the medullary substance of the anterior 
cerebral lobes. 

2. " In another case, whose progress and general character had 
been very similar to those in the preceding one, there was found 
on dissection a well-marked softening or rarnollissement of the an- 
terior lobes. 

3. " A young girl lost her speech after a severe attack of fever. 
When all the active symptoms had disappeared, frictions over the 

j forehead with an ammoniated pommade were employed, and the 
! speech gradually returned. Similar successes attended the use of 
I the same means, in a case where the loss of speech followed a sup- 
pression of the catamenia. 

" M. Gerdy expressed himself unsatisfied with such cases as 
those adduced by the preceding speaker. 
" One single well-authenticated case of decided lesion of the an- 



260 



STOKES'S THEORY AND PRACTICE. 



the upper extremities ; and it is a fact, that in many instances of 
paralysis of the upper extremities, disease has been found in these 
parts. We might term the following a synthetic case, illustrative 

terior lobes, in which the speech was unaffected, is quite sufficient 
he thought to overthrow the phrenological doctrine. Now many 
more than one such case maybe adduced. Thus, in the remarka- 
ble instance reported by M. Andral, of a youth who suddenly lost 
his speech, sight, and intellect, all the symptoms disappeared after 
a certain time ; the speech returned, and also the intellect and 
vision. Subsequently this youth died — the amendment having, 
however, continued to the last, — and on dissection the right an- 
terior lobe of the brain was found to be excessively softened. M. 
Bouillaud himself is candid enough to acknowledge that it is a very 
curious instance, and not easily explicable. Many other such cases 
are to be found in various pathological records. 

" M. Ferrus, one of the physicians of the Bicetre Hospital, replied 
to the observations of M. Gerdy. He was quite willing to admit 
that, while avowing his belief in the truth of the general principles 
of phrenology, he did not give his assent to every doctrine incul- 
cated by its professors, He thought that it required many restric- 
tions, and stood in need of not a few modifications; but in his 
opinion it had already thrown too valuable a light upon the func- 
tions of the brain to merit such reproaches as had been used by 
MM. Cruveilhier, Gerdy, Rochoux, &c, &c. He had satisfied 
himself by numerous researches that the faculty of language is 
really seated, or, in other words, has its material organ in the con- 
volutions of the anterior lobes. I have, says he, over and over 
again observed, that in those persons who are gifted with a striking 
memory of words, and an aptitude for the acquisition of languages, 
the eyes are usually prominent and full, in consequence of the 
great development of the inferior portion of the anterior cerebral 
lobes. The lower part of the forehead too is usually projecting in 
such persons. 

" My pathological observations have led to a similar result ; and 
they are certainly not at all in accordance with those of M. Ro- 
choux. I have, for example, repeatedly observed that, in the ma- 
jority of cases w-here the speech had become affected after the 
delirium of insanity, the anterior and inferior convolutions of the 
brain exhibited striking alterations, either as to the consistence of 
their cineritious matter, or in the relations between it and its invest- 
ing membranes, or in the more deeply-seated medullary substance. 
Three days ago I examined the body of an insane, almost idiotic, 
patient, who had become paralytic : for a length of time his speech 
had been confused, and his condition presented no chance of amend- 
ment. More lately his symptoms had become more acute and 
violent. The excessively congested state of the blood-vessels of 
the meninges and of the substance of the brain accounted for this 
aggravation ; while the unusually strong adherence of the pia 



i 
I 



ENCEPHALITIS. 



261 



of the doctrine :— " A soldier was wounded in the right shoulder 
with a lance, in consequence of which he got an aneurism of the 
axillary artery, for which an operation was performed. At the 
moment the ligature was tightened he experienced exquisite pain 
in the situation of the ligature, which extended to the brachial 
plexus ; this continued until the next day, and then ceased. On 
the fourth or fifth day the pain returned with increased violence, 
and continued until the seventh day, when it became intolerable. 
He was blooded, but without any good effect, he then became 
comatose ; his head was drawn backwards ; he had alternations of 
stupor and excitement, and soon after expired. On dissection, the 
ligature was found to embrace some of the principal branches of 
the brachial plexus, and there was an abscess in the posterior lobe 
of the brain, extending to the optic thalamus." Here we have a 
case of injury of the upper extremity, and that portion of the brain 

mater to the special convolutions — designated by Gall as the organ 
j of language — afforded a rational explanation of the loss of speech 
1 in this case. 

! " M. Ferrus adduced two or three other similar examples in con- 
firmation of the phrenological doctrine on this subject. He then 
alluded to the cases reported by Andral and others, which appear 
to be conflicting with these ; and suggested that most of them are 
far from being conclusive, seeing that in by far the larger majority 
one organ only of the faculty has been injured, its fellow in the 
| other hemisphere remaining the while almost or altogether intact 
But even admitting that both organs have been found seriously 
altered, without the faculty being deeply disturbed, sUch cases by 
no means afford so decisive an argument against M. Bouillaud's 
views, as some of my learned colleagues appear to imagine. Every 
pathologist knows how frequently different parts and viscera are 
found after death almost totally disorganized, which had given out 
during life no very decided symptoms of disturbance or disease. 
If this be true of the brain en masse, and of other organs, why may 
it not be equally so of parts of the brain ? 

" M. Bouillaud closed the discussion — which had continued during 
three seances of the Academy — by replying to the various argu- 
ments and facts which had been adduced by his opponents. 

" Certainly we must acknowledge that the phrenological doctrine 
has on the whole very successfully resisted the attacks of its adver- 
saries during this rather protracted ordeal, and that not a little 
j merit is due to M. Bouillaud for his manly and able defence of his 
I positions. Even M. Cruveilhier admitted that he did not combat 
j a priori the localization of the faculties of the mind ; moreover, 
i that he willingly acknowledged the utility of phrenology, and the 
i services which it had already conferred; but, continued he, 'I have 
j not yet heard sufficient reasons to place the organ of language in 
j one part of the brain to the exclusion of other parts.' " — Gazette 
! Medicate*— B.] 

I 23* 



I 



262 STOKES'S THEORY AND PRACTICE. 



which is supposed to govern it was found in a state of manifest 
disease. Serres gives, also, the details of some experiments in sup- 
port of this opinion. On removing the posterior part of the right 
hemisphere of the brain in a dog, he found that the left anterior 
extremity became paralytic ; he prolonged his incisions into the 
corresponding portion of the opposite hemisphere, and found that 
the right extremity became paralysed. In another dog he plunged 
a bistoury into the posterior part of the right lobe, and found that 
the left anterior extremity became affected with convulsive motions. 
He then introduced into the wound a few drops of nitric acid, so as 
to produce inflammation of that portion of the brain, and observed 
that the convulsions of the left fore-foot became more violent ; in i 
fact, that the animal had all the symptoms of a local inflammation 
of the brain, namely, convulsions, rigidity, and then paralysis. 
Rolando has performed a series of experiments with the same view, 
and his conclusions are exactly those of Serres. So that if we con- 
nect the results of these experiments with some facts drawn from 
pathology, we might conclude that the optic thalami, and posterior 
lobes of the brain, have a very important share in regulating the 
muscular motions of the upper extremity. I may here state, that, 
in this city, a case of a female occurred, who got an attack of severe 
pain in the left hand and fingers, which became afterwards con- 
tracted ; and she had, in addition to this, alternate flexions and 
extensions of the fore-arm, followed by resolution and paralysis. 
On dissection, there was an abscess found in the right optic thala- ; 
mus ; the rest of the brain was healthy. 

With respect to those cases in which there is paralysis of one of 
the lower extremities, it has been taught that it arises from disease ; 
of the corpus striatum. On the anterior lobe the following case is | 
given by Serres. " A woman, forty years of age, had an attack of 
apoplexy, from which she recovered with the left leg in a state of 
complete paralysis, and the left arm admitting of a slight degree of j 
motion." Here was a case of lesion of both the upper and lower 
extremity on the same side, but in the former the paralysis was par- 1 
tial, in the latter complete. On dissection, it was found that two 
circumscribed abscesses existed in the substance in the right hemi- 
sphere, the larger situated in the corpus striatum, the smaller in the ,; 
optic thalamus. Another case is given of a patient who got para- i 
lysis on the side ; the muscular power of the arm being completely 
destroyed, while the leg retained a considerable degree of motion. 
In this case the corpus striatum was but slightly affected, while 
nearly the whole substance of the optic thalamus was destroyed. 
I have also to remark, that Serres performed similar experiments 
on the corpus striatum in dogs, and came to the conclusion, that it 
governs the motions of the lower extremities. The structure, 
extent, and special action of the carpus striatum and optic thala- 
mus, are said to afford some explanation why, in ordinary cases of J 
paralysis, the arm is more often affected than the leg, and does not 
recover so soon. The fact of the prolongations of the optic thalami I 



J 



ENCEPHALITIS. 



263 



being much more complicated and extensive than those of the cor- 
pora striata, is thought to explain their greater liability to disease. 

There are, however, not unfrequent exceptions to this law ; and 
it is not uncommon to meet with cases which militate against the 
doctrines laid down by Serres. and other pathologists, particularly 
so far as regards the connection between the corpora striata and the 
government of the lower extremities, so that I would have you look 
upon it as a point by no means fully established. The latest 
observations on this subject are by Andral, who brings forward 
many facts opposed to the opinions of Serres, Foville, &c, &c. 
Out of seventy-five cases of accurately circumscribed disease of the 
brain, the disease being hemorrhagic, or otherwise, he found that 
in forty, where the paralysis existed in both extremities of one side, 
there were twenty in which nothing was injured but the anterior 
lobe, or the corpus striatum ; while in nineteen the lesion existed 
in the posterior lobe, or the optic thalamus. In these seventy-five 
cases, also, were twenty-three in which one arm was paralysed. 
In these, eleven presented the disease in the anterior lobe, or in the 
corpus striatum; ten in the optic thalamis, or posterior lobe; and 
two in the middle lobe. Finally, out of these cases were twelve of 
paralysis of one arm ; ten of these presented disease in the corpus 
striatum, or anterior lobe; and two only with disease in the optic 
thalamus, or in the posterior lobe. 

These facts prove how uncertain the matter is yet. It would 
appear that when a simultaneous and equal injury of both corpora 
striata and optic thalami exists, it would be natural to expect com- 
plete paralysis of one side, and I believe there are some cases on 
record in support of this opinion. But when you have paralysis 
affecting both sides of the body, you are not to suppose that there 
is necessarily an affection of the corpora striata and optic thalami, 
for such symptoms, in the majority of cases, are found to depend 
upon either an intense congestion of the brain, or a large serous, or 
sanguineous effusion. The same phenomena are produced by the 
pressure exercised by the diseased on the sound hemisphere, in a 
case of local encephalitis, or by disease affecting the upper part of 
the spinal cord. 

With respect to disease of the cerebellum, the only means of 
determining its affections consists in first considering the seat of 
the pain, if any, and, in the next place, the effect on the genital 
system. There are a great number of cases detailed in various 
treatises in proof of the close connection between the cerebellum 
and the genital function. I shall relate a few of these. A man, 
aged thirty-two, got an attack of apoplexy, followed by violent 
erection of the penis, which continued until death ; here we have 
a case of apoplexy accompanied by priapism. On dissection, the 
whole of the cerebrum was found healthy; but there was an 
apoplectic effusion in the middle lobe of the cerebellum. 

Another case is given of a man, aged fifty-five, who died of apo- 
plexy in a brothel, and who, after the attack, had violent priapism. 



264 STOKES'S THEORY AND PRACTICE. 

On dissection, the substance of the cerebellum was found to be 
extensively destroyed, and there was an apoplectic effusion in the 
fourth ventricle. There is a remarkable case on record of a pros- 
titute, in whom the clitoris was extirpated, as it was considered that 
it was the irritation of that organ which brought on a pernicious 
habit, by which her health was greatly impaired ; and it was con- 
ceived that, as soon as the supposed source of excitability was got 
rid of, she would give up her vicious propensity, and be restored 
to health. But in this instance it is probable that the effect was 
taken for the cause ; for on her death, which took place some time 
after, the cerebellum was found to contain a number of chronic 
abscesses. Serres gives the case of a woman, who died of an 
apoplectic effusion into the cerebellum. During the fit, she had 
hemorrhage from the uterus ; and, on examining that organ after 
death, a large clot of blood was found within its cavity, and the 
broad ligaments, ovaries, and, in fact, every part of the generative 
apparatus, were in a state of high vascularity. Yet this female was 
seventy years of age, and her menses had ceased at the usual 
period. There is a most important case bearing on this point on 
record. A gentleman, who was subject to constant and distressing 
nocturnal emissions, consulted his physicians, who, considering . 
them to be the result of debility, prescribed various tonic and 
stimulant remedies. He used various preparations of iron, bark, . 
camphor, opium, hyosciamus, nitric acid, and many other things of I 
a similar kind, but without advantage. From the fact of the 
failure of all these remedies, and the circumstance of his having 
complained of an occasional sense of uneasiness in the back of the J 
head, his physician was led to think that his symptoms might have L 
some connection with an excited condition of the cerebellum ; and, ! 
under this impression, had the back of the head shaved, leeched, , 
and covered with a quantity of pounded ice. From this time his j 
symptoms began to decline rapidly, and in a fortnight he was 
quite free from complaint. Now, this case, taken singly, would 
prove very little; but when we view it in connection with the i 
number of cases in which disease of the cerebellum has been 
known to be followed by excitement of the genital organs, it j, 
becomes of considerable importance. I have now seen two cases L 
in which this connection was observed. In the case of a young 
man, who was brought into the Meath Hospital some time ago with 
paraplegia, it was observed that the penis was in a state of constant 
erection, and there were continual seminal emissions. On dissec- 
tion, an effusion of blood was found in the cerebellum, and another 
in the hemisphere opposite the paralysed side. There was another 
case of a patient who was attacked with apoplexy and paralysis of i 
one side, but with the unparalysed hand he continued to attempt 
the act of masturbation, so that it was necessary to tie down his . 
hand. On dissection, there were several effusions in the substance j 
of the cerebellum. All these facts strongly go to prove the connec- • 
tion which subsists between the cerebellum and the generative 



I 



ENCEPHALITIS. 



265 



function ; and I think it would not be unsafe to make the diagnosis 
of disease of that organ in cases of cerebral disease, where the 
genital system was much excited. 

[A case of this kind was published by Dr. Dunglison some years 
ago, which has been cited as a case of meningitis of the cerebel- 
lum by Dr. Abercrombie. A boy, aged five, pale and delicate, 
after having been slightly indisposed for four or five days, was seized, 
on the 9th of August, with violent convulsions. On the 10th, there 
was fever with delirium ; a vacant look of the eye, and an evident 
imperfection of vision, which appeared by his attempting to lay 
hold of objects that were presented to him, and missing them; the 
pupil was dilated, and there was slight strabismus. On the 11th, 
12th, 13th, and 14th, the symptoms gradually increased. On the 
15th, coma ; constant motion of the right arm and leg; the left ap- 
dearing to be paralysed. In the night, he was seized with violent 
convulsions, which continued till his death, which took place on the 
morning of the 16th. On dissection, the brain was found healthy. 
There was remarkable vascularity on the tuber annulare, forming 
a thick web of vessels. This was connected with the arachnoid 
coat of the right side of the cerebellum, which was thickened, with 
some deposition of coagulable tymph. About four ounces of fluid 
was found at the base of the skull, but not above a tea-spoonful in 
the ventricles. 

An important point in this case, which Dr. Abercrombie appears 
to have overlooked, was the connection between the state of the 
cerebellum and the genital functions ; the latter being much excited, 
and the penis in an almost constant state of erection. See " Case 
of Arachnitis Cerebelli, by Robley Dunglison, &c, &c," in the 
"London Medical Repository," for October, 1822; and Abercrom- 
bie " On Diseases of the Brain," 3d edit., Lond., 1836., p. 60. 

Farther and direct physiological proof of the connection is found 
in the recent experiments of Dr. Budge of Altenkirchen. — The fol- 
lowing are the views of this gentleman on the subject : — 

" It is well known that Gall places the organ of the sexual appetite 
in the cerebellum ; and the remarks of subsequent physicians have 
often been directed to the subject, though without having yet arrived 
at any definite result. For even if one collects all the known cases 
of diseases of the cerebellum, as Burdach has done, one finds, in- 
deed, that an actual affection of the sexual organs has occurred in 
no small number of such cases, but that in a great number, nay, 
even in the majority, none such has existed. In like manner cases 
have occurred to every observant physician which are favourable 
to such a connection of the two organs ; and, again, others which, 
though in other respects similar, afford no such evidence. A more 
certain and incontrovertible proof is wanted; and I have at length 
succeeded, by experiments on numerous animals, in demonstrating 
this influence of the one organ upon the other, in the most simple, 
distinct, and certain manner. 



- 

I 

206 STOKES'S THEORY AND PRACTICE. 

" For these experiments old cats are the best animals that can [ 
be employed; and they may be made upon them either during i 
life, or still better immediately after death. The experiments were r 
repeated so often, that there could not be the least doubt in regard j 
to their result ; and though, in some animals, the phenomena were 
far more marked and distinct than in others, yet in all they were 
so similar, that the relation of one will sufficiently illustrate the • 
whole. 

" In a twelve-year old male-cat, who had been killed by a wound 
of his heart, the whole of the skull was removed as quickly as pos- 
sible, and then the abdominal cavity opened, and both testes, with 
their spermatic cords and vasa deferentia, exposed ; all of which 
occupied but a few minutes. Not the slightest motion was observed 
in the testicles. I now stimulated the cerebellum with the point of 
the knife ; and I had done so for scarcely so much as three seconds, 
when one testicle raised itself up, and moved from the spermatic 
cord on which it had lain, so as to form nearly a right angle with 
it. At the same time it became more and more tense. The more . 
I irritated the cerebellum, the more the testicle moved. I stimu- i 
lated hither and thither, but the two testicles were never moved at : 
the same time. I soon discovered the cause of this remarkable fact. : 
When I stimulated the right lobes of the cerebellum, and the right 
half of the commissure, the left testicle always moved ; when, on 
the other hand, I stimulated the left lobes, and the left half of the 
commissure, then as regularly the right testicle rose up. I had thus 
the movement of the testes entirely under my control, so that I 
could make one or other move as I wished ; and I continued the 
experiment for full half an hour. 

" The cerebellum is, then, the part at which the nerves of the 
testes have their terminal point ; the nerves also cross each other 
in the brain as those of all the rest of the body do ; and they must 
lie tolerably superficial in it, because a deep irritation does not suc- 
ceed in producing the motion of the testes. It seems probable to 
me, that the union of the nerves takes place in the region of the first f 
cervical vertebra, because stimulus of this part of the cord is very 
often accompanied by erection and discharge of semen, as in the r 
hanged, &c. 

" This simple observation is of the greatest importance in many 
physiological and pathological phenomenon. Thus from this con- 
nection, the hitherto inexplicable sympathy between the testicles and | 
parotid gland is accounted for by nervous communication. Perhaps > 
also the relation of the testes to the growth of the beard is explained 
by this connection, since the trigeminus nerve may be traced in its 
ultimate roots to the part where the union of the nerves of the male 
sexual organs may be conceived to take place ; and the nervous h 
trigeminus is distributed in the face, and, most probably, contains 
organic fibres, which are concerned in the growth of the hair. 

" It cannot be thought remarkable, that in so many diseases of the 
cerebellum, the sexual organs should still not suffer. For, in the 



ENCEPHALITIS. 



267 



first place, the whole cerebellum is certainly not to be regarded as 
the central point of the sexual nerves, but only a part of it; and if 
- this part does not suffer, the sexual organs will remain healthy ; and, 
| in the second place, one would be wrong in thinking that every 
j disease of the cerebellum must act in such a manner on those 
organs as to procure a distinctly observable disease. One may 
! suppose that if the part where the nerves meet were compressed, 
I impotence would probably result ; but how many men are impotent 
; without even knowing it." — Mutter's Archiv. Heft. v. 1840. — B.] 



LECTURE XXV. 

I Symptoms of encephalitis — Conclusions as to contraction and paralysis — Remarkable 
cases of encephalitis — Abcesses in the brain — Sympathetic affections — Enteritis 
simulating cerebritis — Prognosis in cerebritis — Remote neuralgia a symptom. 

To-day we again take up the subject of encephalitis ; and allow 
me here to observe on the extraordinary variety and complication 
of the symptoms of this disease. Unless you study with extreme 
care a great number of separate cases of cerebral disease, you will 
never be able to get clear ideas on the nature of this affection, so 
| peculiarly interesting to the pathologist and the practical physician. 
I More circumstances seem to combine in creating a variety in the 
I symptoms of cerebral affections than in those of any other viscus 
i of the body. We have in the case of cerebral disease all the 
variety of symptoms depending on the peculiarity of the part 
engaged, on the complication of local encephalitis with arachnitis, 
on the results of pressure, the nature and extent of effusions, the 
difficulty created by the phenomena of neurosis, and many other 
circumstances. 

At my two last lectures I drew your attention to some cases of 
local encephalitis, in which the disease was pointed out by certain 
affections of the muscular and generative systems. There are 
several other circumstances connected with this part of the subject, 
which are also deserving of attention, and it is necessary that you 
should be aware that there are other sources of diagnosis in cases 
of local encephalitis besides those already mentioned. There is no 
doubt, that though in many cases the occurrence of contraction, 
spasms, and pain in the extremities, precedes that of paralysis, yet 
we may have paralysis from local cerebritis coming on without 
these precursory signs, and as suddenly as in cases of apoplectic 
effusion. This important fact you must never lose sight of. 

Of this I have now seen several instances. I recollect a remark- 
able case of a man who had been bled -in the cold stage of an ague, 
! with the effect of stopping the intermittent. In a few days symptoms 
j of pneumonia set in with great prostration of strength. These 
i were followed by signs of disease of the brain, which were that the 
! patient became suddenly nearly insensible, and on that day was 



! 



268 



STOKES'S THEORY AND PRACTICE. 



observed to have his hand constantly placed on the right side of the 
head. Next day, without any preceding spasms or contractions 
being observed, he was found paralytic in the left upper and lower 
extremities, with paralysis of the left sterno-mastoid, and loss of ! 
sight in the left eye. On dissection we found softening of the two I 
anterior thirds of the right hemisphere, which were of the consist- 
ence of thick cream. The disease engaged the corpus striatum, 
but the optic thalamus was healthy. 

Another remarkable instance occurred lately in a person labour- 
ing under aneurism of the innominata and hemiplegia. Here the 
paralysis came on suddenly, and its cause was found to be an ' 
abscess of the brain. I must observe, however, that there were 
some precursory signs in this case, though contraction and spasms 
were not observed. The patient had violent headache, and was 
subject for some time to occasional numbness and pain in the 
affected arm. > 

I repeat it, you may have the greatest variety in the succession 
and combinations of the symptoms of this disease, and this obser- 1 
vation applies to the lesion of muscular motion, sensation, the state i 
of the intelligence, and the organic functions. You must study i 
numerous cases to get an accurate idea of this disease. I would 
advise you to examine the writings of Lallemand, Bouillaud, Aber- 
crombie, and Serres, on this subject, and then consult the last edi- 
tion of Andral's Clinique Midicale, where you will find the value of 
the symptoms discussed in a most impartial and philosophical man- i 
ner. In this splendid work you will find many cases of cerebritis, in P 
which the symptom of spasm and alternate flexions and extensions • 
was wanting. Indeed he looks upon it as a symptom which cannot 1 
yet be called pathognomonic. 

We may, I think, come to the following conclusions on this 
subject : — 

1st. That local encephalitis is often accompanied by various! 
forms of muscular contraction in the parts afterwards to be 
paralysed. 

2d. That in some cases the paralysis is not preceded by muscular I 
contraction, though various lesions of sensibility may occur. 

3d. That the paralysis may be gradual, (which is the most com-.i 
mon case,) or sudden. 

4th. That the contraction may be intermittent, periods more or 
less elapsing when the symptom is absent. 

5th. That in general the contractions occur in the first, the para- 
lysis in the second stage. 

6th. That in a few cases the reverse occurs. 

7th. That in some cases general or partial convulsions, and in 
others tetanic symptoms, precede the paralysis. 

You will see in the Gazette Midicale, for October, 1833, the 
particulars of a most interesting case, recorded by Berard, jun., o: 
fungous tumours of the dura mater, which was not accompaniec 
by any alteration of muscular motion. This was removed witV 



ENCEPHALITIS. 



269 



the adhering portion of the dura mater, when the patient was 
1 attacked, for the first time, with loss of consciousness and convul- 
| sions of the trunk and extremities. The operator, justly concluding 
; that the sudden removal of the partial resistance of the brain was 
I the cause of the symptoms, applied a piece of agaric to the denuded 
I surface, and made gentle pressure upon it, when he found that im- 
] mediately the convulsions ceased, and the intelligence was restored. 
I Thus, gentlemen, does disease often become a second nature, and 
| its want is the cause of symptoms. 

j As far as we see of the brain, this pathological fact appears cer- 
! tain, that injuries of the upper part of that organ are accompanied 
. by more marked and distressing symptoms than similar lesions of 
! the lower part. There seems, indeed, to be a decided difference 
j between the sensibility of the superior and inferior parts of the 
! brain. The great proportion of those cases in which there was 
i extensive latent disease of the brain, have been cases in which dis- 
ease predominated in or towards the inferior surface of that organ. 
In this situation it has been proved by numerous examples that you 
! may have extensive disease without those symptoms of muscular 
! or mental derangement, which ordinarily characterize inflamma- 
tory affections of the brain. I recollect the case of a patient who 
s was brought into our wards complaining of feverish symptoms, with 
| pain of the left temple, extending to the eye of the same side, 
j With the exception of this pain, he had no cerebral symptoms of 
I any kind ; his intellect was sound, and he was quite free from mus- 
| cular pain, rigidity, spasms, or paralysis. He was ordered to take 
some opening medicine, and to have leeches applied over the seat 
of the pain, but derived no benefit whatever from the application. 
This led me to suspect that something unusual was going on, and 
more particularly when I observed that the leeches were repeated 
without any decided benefit. One morning on going into the ward 
I looked about for him for some time to no purpose ; in fact, his 
countenance was so altered that I could no longer recognise him. 
During the night, the globe of the eye was almost suddenly thrust 
forward by an enormous oedema of the soft parts of the orbit, and 
the pain became excruciating. It was then conceived that the pain 
complained of on admission was the result of disease of the bones 
of the orbit, and that abscess had formed behind the eyeball. 
Under this impression, and in accordance with the earnest request 
of the poor sufferer, it was determined to make an incision to give 
exit to the confined pus. A curved bistoury was cautiously though 
deeply introduced over the eyeball, but on withdrawing it, only a 
small quantity of serum escaped. The swelling went on increas- 
ing, and the eyeball was pushed forward so as to be raised above 
the level of the nose. A curved bistoury was then carried exten- 
sively round the orbit, but without giving exit to any matter. 
Under these circumstances, I came to the conclusion that it was 
an example of deep-seated abscess of the brain, with symptomatic 
oedema of the orbit. This oedema of superficial parts, in cases of 

24 



270 



STOKES'S THEORY AND PRACTICE. 



deep-seated disease, is, you know, a thing of common occurrence, i 
and may be observed in many instances of hepatic abscess, acute 
pleuritis, and other inflammations. In fact, there is such a remarka- 
ble sympathy between deep-seated parts and the integuments over i 
them, that you may have this oedema in deep-seated inflammations 
of the organ. The patient now became gradually worse, his 
agony was intolerable, and the protrusion continued undiminished, 
but he had not either delirium or convulsions. He sank into a 
state of profound coma, in which he remained for about twenty- 
four hours, when death put a period to his sufferings. On dissec- 
tion, there was no pus found in the orbit, and its bones were 
healthy, but in the inferior part of the anterior lobe of the brain 
there was an abscess about the size of a large walnut, resting on 
the cerebral surface of the orbit. I have since learned from several 
of my friends that they have witnessed cases of the same descrip- 
tion. It is an interesting disease, and one which you should be 
acquainted with. I think the existence of the following symptoms 
should lead you to suspect it. First, pain in the head, preceding 
the appearance of tumour of the orbit, and this pain not affecting 
the orbit itself ; for observe, in this case the pain was referred to 
the temple and not to the orbit. The next thing is the pain resist- 
ing ordinary treatment, and being followed by a sudden oedema of 
the parts within the orbit, and protrusions of the eyeball. These 
two circumstances, when occurring in conjunction, should, I think, 
lead you to suspect acute internal disease. Again, in those cases 
where abscess supervenes on caries of the internal table of the 
bones of the cranium, the affection is much more chronic than in 
this or similar instances of deep-seated abscess of the brain. With 
respect to this remarkable symptom of local inflammation of the 
brain, this external oedema, I shall relate the history of another 
case, as I am anxious to throw as much light as possible on this 
obscure subject. It may appear strange, that when a dense bony 
plate and an extremely strong membrane (besides other parts) inter- 
vene between the integuments and the seat of disease, that local 
oedema of external parts should take place as a consequence of 
internal inflammation. Strange however as it appears, it is true, 
and the intervention of the skull does not prevent it, as will be seen 
by the following case. 

A boy was admitted into the Meath Hospital, complaining of 
severe pain in the situation of the mastoid process. He was of a 
scrofulous habit, and had for a length of time a discharge of matter 
from both ears, with slight loss of hearing. Some time before his 
admission the discharge had been very copious, but on being ex- 
posed to cold it was diminished in quantity, and he immediately 
was attacked "with severe pain behind one of his ears. When he 
came into the hospital he was screaming with agony, but had no 
delirium, and the muscular system was unaffected. But what was 
chiefly remarkable in this case was, that, on the second day after 
admission, a distinct tumour formed in the upper portion of the 



ENCEPHALITIS. 271 

| neck, about an inch and a half behind the mastoid process. So 
! distinct indeed was it, that it was generally believed that the disease 
j was periostitis of the base of the skull, which had run on to suppu- 
I ration. An incision was made over the tumour, and the knife 
| was carried down to the bone, but no matter could be discovered. 
! The patient then became gradually worse, the pain was dreadful, 
! but there were no convulsions. Shortly before death he had a few 
I slight muscular twitches, with delirium, and died in great agony. 
I During the whole course of the disease, the discharge from the ear 
, had continued and was remarkable for its fetor. On examining 
i the brain, we found neither abscess nor arachnitis. On slitting up 
, the longitudinal sinus, a remarkable fetid odour was perceived, 
I which increased as the incision was prolonged in the direction of 
the left lateral sinus. Here there was a quantity of extremely fetid 
matter, of an almost cheesy consistence, and mixed with blood ; 
and a communication was discovered between it and the internal 
! ear, the bones of which were carious, and its cavity filled with the 
i same kind of pus. Here we have a curious example of oedema of 
' the external parts depending on deep-seated disease. 
I I shall now relate the particulars of a case in which, although 
the symptoms of an affection of the brain were better marked than 
in the foregoing, still they w r ere by no means so decided as one 
would have expected from the appearances revealed by dissection. 
A patient was brought into the Meath Hospital, with symptoms 
which were thought to be those which mark the ordinary form of 
I delirium tremens. The man had been a great drunkard, but for 
some time back had given up the use of ardent spirits. He com- 
plained of severe and constant pain of the ear, which he stated 
to be of twelve w r eeks' standing, and that it was this which first 
induced him to give up drinking, as he found that it was always 
aggravated by the use of spirits. On admission, he appeared to 
labour under a highly excited state of the nervous system ; he had 
general tremors, and was incapable of keeping up a connected 
conversation, though he could answer a few questions accurately. 
Here we observe a remarkable difference between this and the last 
case detailed, in which there was not the slightest evidence of any 
lesion of the intellectual powers. In the present case, the symp- 
toms were pain, tremors, and incapability of supporting a rational 
conversation, but no decided constitutional symptoms. The pain, 
which had never abated since its commencement, became now 
violently exacerbated, he moaned frequently, and kept his hand 
constantly applied to the affected side of the head. To this last 
symptom I beg leave to direct your attention, as it is an exceedingly 
j common one in cases of local inflammation of the brain. After a few 
, days the mouth was drawn slightly towards the affected side, and 
i it was found that the tongue was protruded in the opposite direction, 
j Symptoms of fatuity now became more distinct, followed by coma, 
I and the patient sank. During the whole course of the disease he 
had no spasms or paralysis of any of the limbs. On dissection, 



! 



272 



STOKES'S THEORY AND PRACTICE 



there was a circumscribed abscess found in the substance of the 
middle lobe of the brain. The abscess itself was encysted, but the 
substance of the brain round it was soft, particularly at its inferior 
part, where it was found to be connected with a carious state of the 
squamous portion of the temporal bone. There was a considerable 
degree of softening in that part of the brain which lay between the 
abscess and the corpus striatum. Here we have a case in which 
pain of the ear is chiefly complained of ; but, in addition to this, it 
was observed that the patient could not sustain a connected con- 
versation, that there was some fatuity, that the mouth was drawn 
to one side, and that coma came on before death. Under such 
circumstances there could be less hesitation in pronouncing the 
disease to be an affection of the brain ; and accordingly we find, on 
dissection, unequivocal marks of disease of the middle lobe, in 
addition to the caries of the temporal bone. 

I might detail many cases of a similar kind, without being under 
any apprehension that I should be occupying your time to no pur- 
pose, for the recital of such cases is better calculated to convey 
information on this obscure subject than any lecture. I shall, 
however, content myself with one or two more. A man, addicted 
to the use of ardent spirits, was brought into the surgical wards of 
the Meath Hospital in a state bordering on coma. It was thought 
at first that he was labouring under typhus fever, and, under this 
impression, no particular attention was paid to the cerebral symp- 
toms for the first day or two. At the end of this period, it was 
learned that he had fallen in going up stairs, while in a state of 
intoxication. His head was shaved, but no signs of wound or 
contusion discovered, though his friends persisted still in their 
statement that he had fallen while intoxicated and hurt his head. 
When admitted into my wards he appeared moribund ; his pulse 
was imperceptible at the wrist, he had extreme coldness of the 
limbs, and a disposition to the formation of gangrenous spots about 
the ankles. He was in a state of stupor ; but when roused an- 
swered questions tolerably well, and said that he had no pain in 
his head. The remarkable feature however in this case, was a 
great degree of muscular rigidity, affecting all the extremities. The 
fore-arm was flexed, and he had not the power of extending it. 
The penis was in a state of permanent semi-erection, but there were 
no seminal emissions. Here was a case in which, taking all cir- 
cumstances into consideration, the cause of the disease seemed to 
be in the brain. He had been drunk, and was supposed to have 
got a fall while in that state ; he was comatose, from which, how- 
ever, he could be roused ; and he had rigidity of the limbs, with 
erection of the penis. With this view I came to the determination 
of treating it as a case of general inflammation of the substance of 
the brain. I concluded that there was no arachnitis, from the fact 
of his answering correctly when roused, while I felt convinced that 
if there was not actual inflammation of the substance of the brain, 
there was at least very intense and general irritation. The treat- 



I 



ENCEPHALITIS. 



273 



merit in this case was successful. After warming the extremities 
by wrapping them in flannel, and the use of artificial heat, the 
| head was shaved, a large number of leeches applied, and an ice cap 
ordered to be worn constantly. The leeching was repeated, and 
he used the ice cap for four days. On the second day after this 
plan of treatment had been entered upon, there was some improve- 
ment, but on the following day the accuracy of our diagnosis of 
j inflammation of the brain appeared, for the patient had violent 
I spasms of the right arm and leg. These however subsided, the 
I coma, rigidity, and other symptoms also disappeared, and the 
! patient slowly but perfectly recovered. In addition to the means 
of treatment already detailed, the patient's system was placed under 
the influence of mercury. 

A question might arise as to the exact nature of this case. Was 
it a case of actual inflammation of the substance of the brain, or 
! was it mere sympathetic irritation produced by some other disease ? 
It may be said that it was a case of gastro-enteritis, with a sympa- 
thetic affection of the head. It certainly might be so, but the great 
probability is, that it was not ; because such symptoms as were ex- 
' hibited in this instance are very rarely the result of gastro-enteritis ; 
and if it was a gastro-enteritis, it is not likely that such complete 
success should have followed treatment directed to the head. 
These circumstances make it likely that it was general irritation 
or inflammation of the substance of the brain itself ; and, if so, the 
case strongly illustrates the utility of mercury, leeching, and cold 
! applications in reduction of encephalitis. The man was brought 
into the hospital in a dying state, and recovered under the influence 
of physiological treatment. 

While I am on this part of the subject, namely, the possibility of 
the head being sympathetically engaged in some instances to a very 
remarkable degree, I may say that the following conclusions on 
this point seem to be fairly drawn. That when an affection of this 
kind depends upon a gastro-enteritis, the signs of cerebral irritation 
are general rather than local. In children who are labouring 
under apparent symptoms of cerebral affection, it has been long 
known that the irritation of the brain may depend on a variety of 
causes. In adults, too, the symptoms of cerebral irritation may be 
the result of ' 4 various affections, of gastro-enteritis, worms in the 
intestinal canal, hysteria, hypochondriasis, and many other diseases. 
In most of these cases, however, particularly with respect to chil- 
dren, the symptoms are general, being pain, delirium, coma, and 
j convulsions on both sides. But we very seldom witness the 
j occurrence of symptoms of local irritation of the brain as produced 
j by sympathy with some other disease, though it is a fact that they 
I may occur occasionally, and without our being able, after death, to 
j discover any existing local encephalitis. A young female was 
l admitted into one of the surgical wards of the Meath Hospital for 
; some injury of a trivial nature. While in hospital she got feverish 
symptoms, which were treated with purgatives, consisting of calo- 

24* 



274 



STOKES'S THEORY AND PRACTICE. 



mel, jalap, and the black bottle, a remedy which deserves the 
name of the coffin bottle, perhaps better than the pectoral mixture 
so liberally dealt out in our dispensaries as a cure for all cases of 
pulmonary disease. She was violently purged, the symptoms of 
fever subsided, and she was discharged. A few days afterwards 
her mother applied to have her readmitted, and she was brought in 
again and placed in one of the medical wards. Her state on admis- 
sion was as follows : — She had fever, pain in the head, violent 
contraction of the fingers, and alternate contractions and flexions of 
the wrist and fore-arm. These muscular spasms were so great 
that the strongest man could scarcely control the motions of the 
left fore-arm. In addition to these symptoms, she had slight thirst, 
some diarrhoea, but no abdominal tenderness. On this occasion a 
double plan of treatment was pursued ; the therapeutic means being 
directed to the head in consequence of the marked symptoms of 
local disease of the brain, and to the belly, from the circumstances 
of abdominal derangement observed in this and in her former 
illness. She died shortly after with violent spasms of the hand 
and fore-arm ; and as she had presented all the ordinary symptoms 
of a local inflammation of the opposite side of the brain, we natu- 
rally looked there first for the seat of the disease. After a careful 
examination, however, no perceptible trace of disease could be 
found in the substance of the brain, which appeared all throughout 
remarkably healthy. She had all the symptoms which, according 
to Serres and Foville, would indicate disease of the optic thalamus, 
or the posterior lobe of the opposite side, yet we could not find any 
lesion whatever of its substance after the most careful examination. ; 
But on opening the abdomen we found evident marks of disease ; 
the lower third of the ileum, for the length of six or eight inches, 
teas one unbroken sheet of recent ulcerations. This case I look 
upon as a very singular one, showing that we may have well- 
marked symptoms of a local irritation of the brain depending on a i 
sympathetic cause. It is fortunate, however, for the study of me- I 
dicine, that such cases form the exception and not the rule. I may i 
remark here on the latency of the enteritis as to the pain. There 
was no abdominal tenderness, a fact illustrative of the great law 
which so particularly applies to gastro-enteric disease, that when I 
the sympathetic affections are prominent, the usual or local symp- : 
toms are proportionally latent. J 
With respect to the prognosis in eases of local encephalitis, the i 
following conclusions seem to be well grounded. Asa general 
rule, the prognosis is to be unfavourable, from the nature of the 
organ, its importance to life, and the frequent complicated and 
obscure nature of cerebral affections. In local encephalitis you 1 
have always two things to apprehend — the acuteness of the disease, 
and its subsequent effects. The patient may die of acute inflam- 
mation, or, if you control this, of the chronic disorganization which 
frequently supervenes, terminating in apoplexy, paralysis, and other 
consequences. On the other hand, it is consolatory to reflect that 



ENCEPHALITIS. 27 5 

I experience has proved the possibility of curing both general and 
I local inflammation of the brain. There are numerous cases on 
I record in proof of the success of well directed treatment. The 
! annals of surgical science are filled with cases of extensive injury 
| of the brain successfully treated ; and it is equally true, that medi- 
j cine can exhibit many instances of well marked idiopathic inflam- 
1 mation of the brain brought to a favourable termination. In making 
! our prognosis on a case of local encephalitis, much will depend 
1 upon the extent to which the muscular system is affected. Spasm 
I of one extremity is more favourable than spasm of both ; and an 
! affection of the muscles of the face is not so unfavourable as of 
I those of the extremities. The next thing to be considered is the 
: age of the patient. In the very young, and in persons advanced in 
life, our prognosis is not to be so good as in the case of one removed 
from these extremes, as neither of the former admit of such active 
treatment ; but of the two, it is better to have to manage the disease 
in a child. It is also singular how well children will often bear 
; active treatment. 

There is another point which should not be omitted. There are, 
; in some cases of local inflammation of the brain, muscular contrac- 
tions and extensions, alternating with a state of rigidity, while in 
j other cases the rigidity is permanent. It is not easy to say which 
of these cases is the worst, but I believe that the most unfavourable 
are those in which we have chiefly violent contractions and ex- 
tensions. Again ; with respect to the cessation of the spasms, it 
! may be considered either as a favourable or a most unfavourable 
symptom. The circumstance of the cessation of the spasms must 
have been produced by some modification in the state of the cerebral 
affection. If it be accompanied by a return of the power of trans- 
mitting proper motion to the affected limb, it is then a sign of great 
value, as showing that the cerebral irritation is nearly gone. But 
if the spasms subside, in consequence of the supervention of resolu- 
tion and paralysis, then the cessation is a symptom of a most un- 
favourable kind, as showing that actual disorganization has taken 
place, which seems to be incurable. 

It may be necessary to remind you that if the patient has, com- 
bined with these spasms, alternations of delirium and coma, it affords 
i grounds for making a bad prognosis* as such symptoms indicate 
that the inflammation has extended to the periphery of the brain, 
and the arachnoid membrane. The state of the intellect is also a 
matter of importance; the more intact and undisturbed it is, the 
greater is the chance that the affection of the brain is confined 
I within a small compass. Here, however, I am anxious to impress 
I this upon your minds, that the absence of delirium should not 
j mislead you, or induce you to form any favourable conclusions on 
| that account alone, in cases of encephalitis, for it is a fact that we 
I may have extensive and fatal disease of the substance of the brain 
| without delirium. I need not tell you that convulsions, or para- 
lysis of one side, do not indicate so unfavourable a prognosis as 



276 STOKES'S THEORY AND PRACTICE. 

where both sides are engaged. Lastly, you should bear in mind 
that cases of inflammation of the substance of the brain are very 
subject to relapse. All these circumstances should be taken into 
account, and a favourable prognosis should be always formed with 
a great deal of caution. 

I alluded in a late lecture to the occurrence of pain in some par- 
ticular part of the extremities, as a premonitory sign of this disease. 
A remarkable case, bearing on this point, has come to my know- 
ledge, and I think I cannot better employ the remaining part of our 
time than in giving a brief abstract of it. A lady got a pain in the 
lower part of the tendo-Achillis, which was considered to be rheu- 
matic, and very little notice taken of it. There was no swelling, 
heat, or tenderness on pressure, in the painful part, and the nature 
of the disease was so imperfectly understood that all the efforts of 
her medical attendants were directed to the heel, but without any 
benefit whatever. Matters remained in this state for some time, 
when she was suddenly attacked with convulsions and coma, and 
died. On opening the head some hours after her demise, a large 
abscess, together with an apoplectic effusion, was found to exist in 
the opposite hemisphere of the brain. There are various other ex- 
amples of a similar kind. I have no doubt that many of those 
anomalous pains are frequently connected with incipient disease of 
the brain. I know the case of a gentleman ; labouring under a 
painful affection of the face, which had got the name of tic doulou- 
reux, and had been subjected to all the variety of treatment which 
persons labouring under that affection so commonly undergo. But 
it has since been proved that his complaint is by no means analo- 
gous to what has been termed tic douloureux, for it has been most 
successfully treated by shaving the head, and applying leeches and 
an iced cap over the seat of the suspected irritation. At present, 
whenever an attack comes on, he immediately gets a bladder, con- 
taining a quantity of pounded ice, applies it to his head, and in this 
way obtains relief. This shows that the severe pain in his case, 
which many would confound with a local affection of the nerves of 
the face, is decidedly the result of a morbid sensibility of the cere- 
brospinal centre. 



LECTURE XXVI. 

Encephalitis — Treatment of in the adult — Importance of energetic means — Dangerous 
effects sf opening the temporal artery or jugular vein — Copious blood-letting from 
the arm — Difficulty of producing syncope — Employment of cold — Good effects from 
purgatives — Encephalitis caused by piles — Treatment — Beneficial effects of blisters 
— Mercury — Dangerous effects of emetics — Dessault's treatment — Use of opium — 
Violent counter-irritation of coma — Application of boiling water — Treatment of par- 
tial encephalitis. 



We have now to enter upon the treatment of inflammation of the 
brain ; and you will find that a knowledge of the general principles 



ENCEPHALITIS. 



277 



of the treatment of cerebral inflammation will be quite sufficient to 
i guide you, even in the management of cases which present apparent 
| exceptions to the ordinary symptoms. The truth is, that the prin- 
ciples which should regulate the treatment of inflammation of the 
brain are nearly the same in all cases. 

I shall commence with the treatment of the acute form in the 
adult. Acute phrenitis in the adult, is an exceedingly severe dis- 
ease, characterized in its first period by an high exaltation of the 
; functions of the brain, and in its second by a corresponding depres- 
| sion. In this form of disease we have generally high fever, a 
strong, bounding pulse, throbbing of the carotids, intense pain of the 
I head, great brilliancy of the eye, with intolerance of light, vivid 
redness of the face, a ferocious countenance, and furious delirium. 
| Under such circumstances there is no time to be lost; the brain is 
j a delicate organ, and cannot bear much disease, and its powers of 
recovering from idiopathic disorganization seem much less than 
those of the lungs or abdominal viscera. Indeed, we must believe 
> that, notwithstanding the assertions of Lallemand, it remains to be 
! proved that recovery can take place after the stage of softening has 
set in, in idiopathic encephalitis. The brain differs from the lungs 
or digestive organs in having no excretory duct for the products of 
| inflammation, and hence one cause of the greater danger of its idio- 
pathic inflammations than its traumatic, where an opening is formed 
| in the skull. In such a case you have to apprehend two patholo- 
gical lesions, the inflammatory softening of the substance of the 
brain, and the inflammation of its serous membranes, with effusion 
into their cavities. The patient, too, may die from congestion, or 
even an apoplectic effusion may occur, illustrative of the proposi- 
tion of Broussais, that all encephalic irritations may produce an 
apoplexy. I have seen this termination, even in the infant under 
a year old ; in such a case I once saw an apoplectic effusion which 
had supervened in the course of an arachno-cerebritis, and which 
amounted to several ounces of blood. Every moment is precious, 
and no consideration should induce you to put off, even for an hour, 
the adoption of the most rigorous measures. In the first place, you 
must bleed ; and here let me remark that blood-letting should be 
performed so as to make a decided impression on the symptoms. 
It will often happen, that, from the state of uncontrollable fury 
which the patient is in, it is dangerous and almost impossible to 
bleed him. Here you must endeavour to moderate the delirium, 
and there is no way by which you can accomplish your purpose so 
fully as by cold dashing. Where there is high delirium, I believe 
you will always find it the best plan to precede venesection by 
throwing a few basins of cold water over your patient's head. 
This will procure an interval of comparative tranquillity, during 
which you can open either a vein or an artery with convenience 
and safety. Of course, if anything like collapse ensues (which is 
possible) you will not bleed immediately. The object of the cold 
pouring, under these circumstances, is to obtain such a diminution 



278 



STOKES'S THEORY AND PRACTICE. 



of the fury as will allow of your bleeding the patient with safety, | 
as to the operation. If you cannot reduce the cerebral excitement p 
by this means, it will then be necessary to put on the strait waist- r 
coat, pro tempore. There is a difference of opinion among medical 
men with respect to the mode of abstracting blood ; some prefer f 
taking it fro m the arm, some from the jugular vein, and some from 1 
the temporal arlery. Now, I am inclined to think that it is better \ 
to open a vein in the arm, and that venesection performed in this p 
way will be found to answer every purpose. It is said that if you I 
take blood from the temporal artery or jugular vein, you deplete \ 
the brain more directly than you would by opening one of the it 
brachial veins. This may be true, though 1 think it still remains i 
to be proved that the drawing of a smaller quantity of blood from p 
these vessels will have a more powerful effect on the system than d 
from the arm. If you open the temporal artery, there are two i 
disagreeable circumstances which you should be prepared to meet. [ 
In the first place, the patient is in a state of furious delirium, you : 
don't know how long this may last, and it may happen that in one i 
of his paroxysms he will tear off the bandage, and, if not watched, , 
bleed to death. A case of this kind occurred not long since in the 6 
person of a gentleman of this city, who had the temporal artery \ 
opened. He tore off the bandage, and a terrible hemorrhage 
ensued ; assistance was procured, and the bandage re-adjusted ; he 
tore it off a second time, and died shortly after, his death being i 
evidently accelerated if not actually caused by the quantity of blood i 
lost. Again, it is possible that an aneurism may be formed as a j: 
consequence of the operation, which may excite a determination to i 
the head, and tend to keep the patient in a state of excitement. 
Thirdly, you must employ a bandage to secure the artery, and to > 
this there is a strong objection, in consequence of the pressure 
which it makes on the external vessels of the head. I am there- ; 
fore strongly opposed to opening the temporal artery in cases f 
of acute inflammation of the brain, accompanied by high mental i 
or muscular excitement. Now, with respect to the jugular vein, « 
you are aware that to command this vessel pressure is also required, j 
How this pressure can be made without interfering with respiration o 
and compressing the veins of the neck, so as to add to the existing ' 
congestion of the head, I am at a loss to know. I would advise 
you, therefore, when you bleed in phrenitis, to prefer opening a - 
vein in the arm ; by making a free incision you can draw blood in • 
such a way as to make an impression on the system, fully equal to 
that produced by either of the foregoing modes ; and without sub- 
jecting your patient to the same degree of inconvenience or risk. 
The quantity of blood to be taken away must be regulated by the 
age, strength, and constitution of the patient, as also by the intensity 
of the disease. Where you have to deal with a young man of 
robust constitution, your first bleeding may amount to thirty 
ounces. You will often find it difficult to produce fainting in this 
disease, for the excited condition of the brain keeps up a constant 



ENCEPHALITIS. 



279 



determination to that organ, and prevents syncope. The same 
difficulty is met with in cases of hypertrophy of the left ventricle, 
which causes a great determination to the head. 

Your next step is to have the head shaved. Never omit this. 
The very circumstance of freeing the head from the covering of 
hair, and permitting the free contact of air with the scalp is of 
advantage ; and if you wish to employ cold applications, you can- 
not do so properly without premising this operation. After you 
have done this, you should apply a large number of leeches to the 
| scalp, or if you cannot readily procure leeches, employ instead of 
' them light scarifications to the temples and nape of the neck, and 
j keep on the cupping-glasses until you have obtained a sufficient 
: quantity of blood. By acting in this way with promptness and 
! decision, you arrest the violent symptoms and gain time. 

In treating a case of this kind it is a very common practice to 
use cold applications. They are for the most part applied in shape 
of a cold lotion to the head, but I need not tell you that this is a 
very imperfect mode of using them, and indeed I have seen but 
' very few persons who were acquainted with the proper mode. 
Persons are in the habit of supposing that the mixture of a certain 
quantity of saline ingredients with water should produce a very 
j cold lotion, and so it does indeed while the salts are dissolving ; 
| but as soon as this is accomplished, the mixture rapidly acquires 
I the temperature of the surrounding air. The solution is generally 
' prepared by the apothecary, (and sent in a bottle, as if they could 
' cork up the cold,) but the cold is quickly lost, and, in a few mo- 
ments after the lotion has been applied, you will find it tepid, and 
passing into a state of vapour. Now if you wish to derive any 
j benefit from the use of cold applications, you must stand by your- 
self, and see the thing properly done. The object is to have the 
scalp kept constantly cold, and this can be done only by the repeated 
application of cold lotions. If you prefer saline lotions, you should 
have them made by the bedside, and applied while in the act of solu- 
tion, or you should put a quantity of ice into your lotion, for while 
a single piece of the ice remains undissolved, the temperature of the 
lotion will be very little above the freezing point. A very good 
way is to have a jar of cold water with a quantity of ice in it, and 
i to apply clothes dipped in it every minute, taking care not to im- 
merse the hot cloth into the iced water until it has been wrung out 
in another vessel of water. You may also use the ice cap, though 
this is a painful remedy. But the mode of using ice to the head, 
which I prefer in all cases, and particularly in that of the child, is 
to take a piece of smooth ice, about the size of a dollar, and half 
I an inch thick ; this is to be placed in the hollow of a fine cup sponge, 
j and steadily moved over the whole shaved scalp. By this mode 
• J you prevent the pain which the iced cap produces, and the sponge 
i I absorbs the water produced by melting, and the application may be 
i j continued for an indefinite length of time. But one of the best 
[ modes of applying cold to the head is that recommended by Dr. 



I 



280 STOKES'S THEORY AND PRACTICE. 



Abercrombie, and, as far as my experience goes, 1 can safely affirm 
that there is scarcely any remedy of such unequivocal value in 
acute inflammation of the brain or its membranes. Dr. Aber- 
crombie's mode is this — the scalp being first shaved, you direct the 
patient's head to be held over a basin, and then taking a jug of cold 
water, pour its contents over the head from some height in a small 
continuous stream. This measure, simple as it may appear, is one 
of extraordinary efficacy. In fact, so great and instantaneous is 
the depression of the vital power produced by this mode, that it 
must be used with caution. There are numerous cases of persons 
in the highest state of maniacal excitement, reduced in a few mo- 
ments to a low and weak state by this powerful remedy. There 
are also instances of its rapidly depressing effect in the early stages 
of acute hydrocephalus. I have used it more in the phrenitis of 
adults than in the hydrocephalus of children; but in the latter disease 
I know many instances- of its value, and believe it to be only second- 
ary to the application of leeches. In acute inflammation this form 
of cold effusion should be employed every hour or half hour, ac- I 
cording to circumstances, and if you wish to increase its efficacy j 
you can do it by placing the patient's feet in warm water at the 
time of its application. Here, then, gentleman, is the first set of 
remedies you should employ in a case of acute phrenitis ; a full 
bleeding from the arm, premising it, if there be great maniacal 
excitement, by dashing a basin of water over the patient's head; 
shaving the head, and applying a large number of leeches, or if 
these are not within reach, the use of cupping; and, lastly, the 
constant application of cold lotions, or the use of the cold affusion 
after the manner employed by Dr. Abercrombie. These are the 
great measures which should be boldly and promptly put in prac- 
tice, in order to counteract the first violence of a case of acute 
inflammation of the brain. 

You will next act upon the bowels by purgatives. This is a 
matter of the deepest importance, for there is hardly a disease in \ 
which the judicious administration of purgatives has teen followed 
by more decidedly beneficial effects, than in inflammation of the L 
brain, where the digestive tube has been in a healthy condition. 
Purgatives are also found to be of great benefit in the simple 
hydrocephalus of children, and in several cases it has been ob- 
served that the disease did not yield even after active bleeding, j 
until purgation had been employed. Dr. Abercrombie speaks in 
the highest terms of the value of purgatives, even after coma has 
set in. The purgatives which are generally used are those of the 
drastic kind, and they may be given by the mouth or in the form of 
enemata. 

Such are the rules for the treatment of the ordinary form of acute 
encephalitis. I shall now make a few observations with respect to 
the local applications. It may not be necessary to repeat the vene- 
section, particularly if the means which I have recommended be 
put in practice in a regular and proper manner, but it will in most 



ENCEPHALITIS. 



281 



cases be requisite to repeat the leeching. Even in the advanced 
i stage of the disease, and after coma has made its appearance 
Dr. Abercrombie lays great stress on the benefits derived from the 
application of leeches ; and I think I have myself saved some lives 
by the employment of leeches, even after the supervention of coma. 
In all violent cases I would recommend strongly to you the using 
! relays of leeches from the first, to keep up a continual detraction of 
! blood. In addition to this, the patient must be kept perfectly quiet, 
! all loud sounds, and the stimulus of light avoided ; the room should 
j be kept cool and well-aired, the bed-covering light, the attendants 
few, and the nurse should be a person of cool temper and steady 
| disposition. 

These are the principal measures to be employed in the treat- 
j ment of acute inflammation of the brain in the adult ; there are 
j certain cases, however, in which you may add to these measures 
others of a different kind, particularly in cases where the disease 
has occurred as a consequence of the metastasis of inflammation 
from other parts. Suppose you have a case of rheumatism, or of 
some suppressed evacuation in which there is a metastasis to the 
brain. Under such circumstances, while you employ the means I 
have mentioned for the purpose of subduing cerebral inflammation, 
you will also put in practice the best measures for restoring the 
original disease. Here, however, you should bear in mind, that 
your attempts to bring back the original disease are always to be 
looked upon as secondary to those for the direct removal of the 
existing irritation of the brain. Some practitioners, in such cases, 
content themselves with endeavouring to restore the original affec- 
tion, but this is playing a dangerous game. An organ of vast 
importance to life is affected, and you cannot calculate how far the 
inflammation may proceed. You should never neglect taking 
proper steps at first to reduce inflammation, while at the same time 
you need not neglect the means calculated to bring back the former 
disease. If the encephalitis be caused by the suppression of bleeding 
piles, or a sudden checking of the menstrual flux, leeches to the 
anus or vulva are found useful along with the direct treatment. If 
the disease be produced by the repression of an exanthematous 
I eruption, the same principles apply. You should never omit em- 
j ploying the means for bringing back the original affection, but you 
I should always recollect that they are to be secondary to the mea- 
j sures adopted to directly relieve the cerebral excitement. 

With respect to the use of blisters, the same rules apply here as 
! in other cases of disease treated of during the course. They are 
never to be used in the early stage of the disease, and while active 
! inflammation is present ; and, as a general rule, I believe it is 
I better to apply them to the nape of the neck, or the inside of the 
| legs, than directly to the head. There is only one case in which 
j you can apply them with advantage to the head itself, and this is 



282 



STOKES'S THEORY AND PRACTICE. 



where there is coma with a cool skin. Here the stimulus of a 
blister is frequently found to be highly useful. 

As to the use of mercury in cases of acute cerebral inflammation, 
I think we have not as yet a sufficient number of facts on which to 
form any decided opinion. If we look to hydrocephalus, we shall 
find that there are many cases in which the symptoms did not yield 
to the ordinary measures until mercury was employed ; this, how- 
ever, we do not find to be so much the case in the acute inflamma- 
tion of the brain in the adult. I shall return to this subject on a 
future occasion. 

I have little doubt that emetics are very dangerous in this disease, 
from the determination to the head which they produce. 

Any of you, gentlemen, who has vomited, cannot forget the vio- 
lent sense of tension about the head with which the act is accom- 
panied ; and, if the brain be in a state of acute inflammation, you 
can readily conceive how injurious such an effect must be. The 
use of emetics in this disease has been adopted in consequence of 
a misconception of the opinions of Dessault. He attributed extra- 
ordinary efficacy to the use of tartar emetic, in cases of injuries of 
the head. But you must be aware that Dessault did not give tartar 
emetic so much with the view of exciting emesis, as of 'producing 
a degree of nausea calculated to keep down inflammatory action. 
Moral, who was a pupil of his for five years, makes a statement to 
this effect, and says that so far from proving beneficial when it 
vomited, the tartar emetic was always attended with unfavourable 
results. When it acted on the skin, or by stool, he says the effects 
were favourable ; but when it vomited, the symptoms of cerebral 
excitement were always increased. Under these circumstances, I 
think you should be cautious in having recourse to the use even of 
tartar emetic, after the manner of Dessault ; for even in this way 
you run the risk of vomiting. On this point we have eight very in- j 
structive cases given by Lallemand. In the first two cases, where 
emetics were used, the head had been merely threatened. The | 
emetics were followed by profuse vomiting, and this by symptoms 
of violent cerebral excitement and rapid death. The third case j 
was that of a patient who had apoplexy : the emetic was followed 
by symptoms of inflammation of the brain and death. On dissec- 
tion, there were marks of inflammation discovered round the clot. 
Now it has been observed, in several instances, that where the sub- 
stance of the brain round an apoplectic clot became inflamed, that, 
in addition to the phenomena of apoplexy, symptoms of a spasmodic 
affection of the muscular system supervened. Here we see, that 
after the use of an emetic these symptoms appeared, and their 
nature was verified by dissection. In the remaining five cases, 
where emetics w r ere employed, the cerebral affection was rather 
increased than diminished ; and, in some of them, disease of the 
digestive tube was superadded. Weighing these circumstances 
calmly, I think the use of emetics in acute inflammation of the brain 
may be considered dangerous. 



ENCEPHALITIS. 



283 



With respect to opium I must say, that I am strongly opposed to 
its employment, at least in the early stage of encephalitis. I have 
seen many cases of hydrocephalus in children, in which opium 
seemed to be decidedly injurious; and I believe that in all cases 
where there is congestion of the brain, its employment will be at- 
tended by bad effects. But when all the symptoms of active inflam- 
mation have passed away, and when there remains a peculiar 
nervous condition of the brain, characterized by symptoms of men- 
tal excitement and persistent watchfulness, somewhat resembling 
delirium tremens, here, I believe, that you may have recourse to 
opium with much benefit. In many cases where the antiphlogistic 
treatment had been properly employed at the commencement, there 
frequently remains a neurotic condition of the brain, accompanied 
by great irritation and absence of sleep ; and in such cases I have 
seen much good resulting from the use of opiates. When I speak 
of fever I shall return to this subject. 

In the treatment of this disease, I am anxious that you should 
always bear this principle in mind — that you cannot be too cautious 
in adopting means of coercion. Coercion has always a bad effect : 
it should never be resorted to, except in cases of extreme necessity ; 
and you should never suffer the patient's attendants to employ it 
without your express permission. It is a common practice in hos- 
pitals, where the attendants always wish to save trouble, to put on 
the strait w T aistcoat as soon as the patient exhibits symptoms of 
delirium. What is generally the result of this treatment? The 
poor sufferer becomes irritated by confinement, and uses the most 
violent efforts to liberate himself ; his struggles increase the excite- 
ment of the brain, and prevent the measures you employ from 
taking effect. I have known many melancholy cases, illustrative 
of the abuse of the strait waistcoat. I shall give you one: — A 
female, of delicate habit, was attacked with fever and some deli- 
rium. She was supposed to labour under disease of the brain. 
They put a strait waistcoat on her, and tied her down to the bed, 
where she remained for several days in a most deplorable state. 
A medical man, who was called in to see her at this time, found 
her in the situation described, with her head shaved and blis- 
tered,, and her strength sinking. It struck him that there was 
something peculiar in the case, and he asked her several ques- 
tions with the view of testing her sanity; and, finding that she 
answered rationally, he immediately directed that the strait waist- 
coat should be taken off. She then told him that, during the whole 
course of her illness, she had laboured under pain of the right 
side. He examined her side, and found a large tumour in the situa- 
tion of the liver. There was also an eschar on the back. She 
died shortly afterwards ; and, on dissection, the liver was found to 
be in a state of extensive suppurative disease ; the brain perfectly 
healthy. It is unnecessary for me to make any comment on 
this case. 

While, however, I deprecate coercion as a common mode of 



284 



STOKES'S THEORY AND PRACTICE. 



proceeding, I fully admit that cases will occur that demand it for 
the safety of the patient. The dreadful tendency to suicide is one 
of the characters of this disease, and must never be forgotten in any 
case. All that I wish to impress upon you is, that coercion must 
be used with great caution, and only so long as it is absolutely 
necessary. When we come to treat of the nervous systems in 
fever, I shall recur to this subject. 

In all cases of cerebral disease you should never omit inquiring 
into the state of the bladder, for there is often retention of urine. 
This is to be obviated by drawing off the urine with a catheter, two 
or three times a day. 

You wiill meet with cases of cerebral inflammation in the last 
stage, with profound coma, general paralysis, an imperceptible 
pulse, and tracheal rattle. It is a melancholy thing to be called to 
a case of this description, where the ordinary means furnished by 
medicine are so inadequate to the removal, or even the alleviation 
of symptoms ; and yet it is a fact that, even under these circum- 
stances, cases have been cured by the adoption of an extraordinary- 
measure. This consists in the employment of enormous and 
sudden counter-irritation, by pouring boiling water over the lower 
extremities, while, at the same time, ice is applied to the head. 
This is certainly an extraordinary and barbarous method ; but it 
has succeeded in rescuing the patient, as it were, from the jaws of 
death. One of the most singular cases of this kind is recorded by 
Lallemand — that of a man upwards of sixty, who, in consequence 1 
of a fall on the head, was attacked with encephalitis, which was 
mistaken for an essential fever until the tenth day. At this time he ' 
was first seen by Lallemand, who found him labouring under severe 
and long-continued syncope; the right extremities flexed : the hand 
firmly closed ; the surface on this side insensible ; the eyelids 
closed; the eyes turned up, squinting, and insensible to light ; com- I 
plete loss of hearing and intelligence. The body was covered with 
a 7 cold viscid sweat; the respiration frequent and stertorous, and 1 
the pulse absent. Lallemand' proposed pouring boiling water on 
the ankles, and, at the same time, applying ice to the head, an 
advice which was consented to with great reluctance by the other 
medical attendants. At the moment the boiling water was applied, j 
there -was a sudden motion of the whole body: the left arm was ! 
agitated, the eyes opened, and the pulse could be felt at the wrist. 
In half an hour the boiling water was applied to the thighs with 
still greater effect ; colour returned to the face, and the pulse 1 . 
became fuller. From this time improvement went on. Deep - 
suppurating wounds w T ere produced by the boiling water which 
took more than six weeks to cicatrise. The patient's recovery was 1 
perfect. 

In Dr. Mackintosh's work you will find this practice recom- ■ 
mended. It is indeed an extreme remedy, and one which, for 1 
many reasons, practitioners would have repugnance to use ; but 
it is well to be acquainted with such a powerful remedy, and 



ENCEPHALITIS. 



285 



to know that it has succeeded under the most desperate circum- 
stances. 

With respect to partial encephalitis, the principles of treatment 
are the same. In this form of disease you will often have to con- 
tend with the prejudices of the patient, and sometimes of practi- 
tioners who do not recognise its existence. Its symptoms, you will 
remember, may at first appear slight or insidious, and to the super- 
ficial observer less referable to the head than elsewhere : yet the 
disease is full of danger, slight though it appear. The recent 
researches on this subject have shown, too, that it is commonly a 
comparatively acute disease. Andral gives a table, showing the 
periods in one hundred and five cases : in eighty-nine of them death 
occurred within a month. The liability, too, of secondary compli- 
cation, with general congestion, arachnitis, or apoplexy, must be 
always borne in mind. 

When the symptoms of a local encephalitis are decided, I think 
you should always commence by bleeding from the arm, and then 
apply relays of leeches and cold lotions to the opposite side of the 
head. You will also find the application of tartar emetic ointment, 
so as to bring out an eruption as soon as possible, of great value in 
cases of this kind. Above all things, take care to relieve the symp- 
toms by prompt and decided measures before the stage of paralysis 
comes on, for when this arrives, I believe you can do very little in 
the way of cure. I have seen three cases in which, after the deple- 
tions, the symptoms were relieved by bringing the patients rapidly 
under the use of mercury; and I think local inflammation of the 
brain may be treated by mercury as well as localised inflammation 
of other parts. My late lamented friend, Dr. Leahy, communi- 
cated to me the particulars of two cases in which pain, spasms, and 
other symptoms of a local encephalitis were present, and in which 
complete relief was obtained as soon as mercurial action was 
brought on. I recollect an old lady who got pain in the right side 
of the head, with contraction of the finger of the left hand, and 
alternate flexions and contractions of the fore-arm, accompanied 
by slight lesion of the intellectual functions. She was leeched 
three or four times, blistered, and purged, without any decided 
relief. I then determined to try the effect of calomel, and was 
gratified to find that, according as her mouth became affected, the 
pain and contraction of the fingers, as well as the motions of the 
fore-arm, diminished considerably, and as soon as full ptyalism was 
established all her symptoms disappeared. This case is particularly 
interesting, inasmuch as it shows that the ordinary treatment by 
leeching, counter-irritation, and purging, failed in giving relief, so 
that we are justified in attributing some value to the use of mercury. 
In the advanced stages of this disease, it seems right to employ a 
seton in the back of the neck ; and I would advise all who have 
been attacked to continue the use of this remedy for a great length 
of time. 

The term ramollissement, or softening of the brain, is one which 

25* 



286 STOKES'S THEORY AND PRACTICE. 

is very extensively used, and I fear often without any precise idea 
of its meaning. In ninety-nine cases out of a hundred this ramol- 
lissement will be found to depend upon local inflammation of the 
brain ; of this I do not entertain the slightest doubt. I think we may 
very safely eonsider.it as analogous to the softening of the lungs, 
liver, or spleen, or from inflammation of their texture. There is a 
peculiar softening of the brain in old persons, which we cannot con- 
nect with actual inflammation, but in all cases in the child, and in 
almost every case in the adult, ramollissement of the brain will be 
found to depend on inflammation. I do not mean to infer from this j 
that it is in our power to cure every case of softening of the brain, 
for when it once sets in, the great probability is that the texture of 
the affected part is destroyed ; but we can cure many cases by "> 
subduing the inflammation from which it derives its origin. Of ) 
course we cannot expect to accomplish this in the case of old per- \ 
sons, where the symptoms come on without any inflammatory phe- f 
nomena, as in that peculiar softening of the brain which forms the h 
subject of Rostan's work, and occurs in persons beyond the age of 
seventy. This appears to be a species of senile gangrene. That i 
form of ramollissement, which occurs in adults and children, is, i 
however, very different from this, being, in the vast majority of 1 
cases, the result of inflammation. You will hardly ever dissect a 
case of partial encephalitis in the adult, or of hydrocephalus in the i 
child, without finding more or less of this inflammatory softening. 

[As the remarks of Dr, Stokes, in this and a subsequent lecture, 

on ramollissement or softening of the brain, are more allusive than J 
explanatory, I subjoin a few additional particulars. 

A Diminished Consistence or Softening of the Brain, En- \ 
cephalomalacia, is found in various fevers, in rickets and tubercular 

disease of man and animals, in consumption of the lungs and dia- \. 

betes, and in mental diseases, but especially in dropsy of the brain, jj 

More generally, however, and also more distinctly, the softening is t 

of certain parts only of the brain, either in consequence of inflamma- j 

tion, or as an effect of a peculiar process of conversion. Rostan, I] 

(TraitS Elementaire de Diagnostic, de Prognostic, ^-j Tome II., j 

p. 279,) says that softening or ramollissement, as he terms it, of * 

the cerebral or pulp, results from inflammation, 1, when the colour ; 
of the altered part is rosy ; 2, when it contains a certain quantity 

of pus ; 3, when febrile phenomena have been observed during life. !j 

Softening of the brain has not an inflammatory character, ac- 
cording to the same authority, 1, when the colour of the altered 

part is whiter than natural, and when this whiteness cannot be at- r ; 

tributed to an intimate mixture of pus with the cerebral substance, ' 

which is quite common ; 2, when the sanguineous injection is dis- I 

played by a number of points, or even by true ecchymoses in the ■■ 
diseased part: in these two cases the softening may be the effect 
of an abortive hemorrhagic effort which merely produced irrita- 
tion, such as, for example, that which gives rise in other organs to 



[SOFTENING OF THE BRAIN.] 



287 



I a scorbutic disposition ; 3, when, during life, there was no febrile 
; symptom which could induce a suspicion of the existence of any 
! irritation ; but, on the contrary, all the phenomena w^ere evident, 
i which would point out an undoubted scorbutic or hypothenic state. 
I The last or the non-inflammatory variety is much more common 
I than the other in old persons. 

The local symptoms of functional disturbance, or the derange- 
1 ments of cerebral function, are the same in both varieties ; but it is 
not so with the general symptoms. The immediate functional 
| phenomena are divisible into two periods. In the first, there is 
generally pain of the head, vertigo, and a weakness of the intellec- 
tual and moral faculties, drowsiness, formication, pricking sensation 
and numbness in one limb ; together with a difficulty in taking hold 
j of objects, particularly if they are of small size. The sensibility is 
j usually diminished ; and vision is disturbed, being less accurate 
than common, and sometimes there is entire blindness; so also with 
the hearing, which is impaired. 

If the softening is inflammatory this first period is shorter, and 
is marked by greater intensity of the symptoms; more acute pain 
of the head ; abruptness of reply ; and often delirium. The sensi- 
bility of the limbs is frequently great ; the patient complains of 
pains in them, more or less violent ; they are sometimes stiff and 
contracted : the senses are very irritable, and unable to bear their 
appropriate stimuli. The functions of organic life present no- 
i thing characteristic ; the disturbances of function in it being met 
with in other diseases. The pulse, we are told, is softer, slower, 
and- weaker than natural in the non-inflammatory variety; but in 
the inflammatory it is strong and frequent, with hot skin and great 
thirst. 

In the second period the patient loses the use of a limb, or even 
of one side of his body, suddenly or gradually, but for the most 
part suddenly. In general, the intellect is not impaired ; although 
the patient is very slow of speech, and only succeeds in making 
himself understood by painful gestures. Sometimes there is com- 
plete coma. If the coma and paralysis have come on suddenly, the 
patient usually recovers his consciousness on the day after the 
| seizure. This is explained by the complication of cerebral con- 
gestion with softening of the brain. The symptoms soon return, 
however, with increased violence ; the intellect and the functions of 
the senses are entirely destroyed, complete coma supervenes ; the 
limbs become immoveable, and death closes the scene. 
! In the inflammatory softening, in place of paralysis, there are 
j pains darting through the limbs, contraction, convulsions, and 
more or less intense cephalalgia. In both varieties of the disease, 
I when there is headache, if we ask the patient where is the seat of his 
| pain, he raises slowly his sound hand to the head, and commonly 
i points out the side of it opposite to that paralysed. 

. In this second period the changes in the nutritive functions, or 
! organic life, are of a marked nature. There is loss of appetite ; 
we see the teeth dry, the tongue rugous, chapped, brown, and even 



288 STOKES'S THEORY AND PRACTICE. 

black, deglutition painful, and finally impossible. Sometimes there | 
is vomiting of alimentary matters, and then of bile, with an invo- 
luntary excretion of urine and faeces ; often there is constipation ; 
the breathing is laborious, and towards the end stertorous; the 
pulse is weak, often irregular and intermittent ; the skin is cold. 

The organic changes in the brain noticed after death vary in 
consistence, colour, seat, extent, and number. The membranes are 
almost always infiltrated with serosity, and exhibit a gelatinous s 
aspect. The effusion here, as on other occasions, must be regarded 
as consecutive on the softening, but it is not the less a contributing 
cause of the comatose symptoms seen towards the termination of 
the disease. When the softening has been inflammatory, the mem- 
branes are sometimes dry, red, and injected ; in some cases they 
are covered with suppuration, and adhere to the softened cerebral 
portion. The consistence of the brain varies from that of thin 
naush to the natural firmness of the organ. When the softness is j 
inconsiderable, there must be a change of colour in order to enable j 
us to recognise it. This colour is rosy, red, yellow, greenish, ac- 
cording to the degree of inflammation ; it is of the colour of wine- > 
lees in scorbutic ecchymoses and in abortive hemorrhagic effort: r 
and is finally of a pure milk-white in those subjects in which there t 
had not been, during life, any inflammatory symptom. 

The softening may be either superficial or deep-seated. If the \ 
first, the convolutions are deformed, swelled, and rounded to a va- 
riable extent ; and the gray or cortical substance is removed with 
the slightest friction. In the second case, the softening may occupy 
all parts of the brain ; but the optic beds, striated bodies, and the 
middle lobe, are the most frequent seats of the lesion. Its extent is \ 
variable, from the size of a French bean to that of an entire 
hemisphere. The lesion is commonly unit; but sometimes both 
hemispheres are affected : finally, we meet in certain cases with a b 
great number of softened points. There are ecchymoses like scor- ;j 
butic spots. The ventricles in general contain a quantity of sero- 
sity which might impose on some the belief of there having been < 
hydrocephalus. The arteries of the brain are frequently ossified. \ 

For many interesting facts and ingenious suggestions respecting i 
softening of the brain, I would refer the inquisitive reader to the ! | 
Recherches Anatomico-P athologiques sur VEncephale et ses De- 1 
pendances, by Professor Lallemand of Montpelier. — B.] 



LECTURE XXVII. 

Analysis of symptoms of cerebritis — Inconstancy of pain — Arachnitis, pain of — Inter- 
mittent pain— Headache — Phenomena of the eye— State of the pupils— Various ■ 
affections of the functions of vision — Researches of Parent and Martinet — Relief by- 
convulsions — Brain considered as a secreting organ— Dangerous effects of opium; 
delirium — Phenomena of organic life — Vomiting in hydrocephalus — Sympathies of 
the digestive and respiratory systems — Treatment of hydrocephalus — Of internal 
remedies — Cancrum oris, treatment of. 

Before we leave the subject of inflammation of the brain, I shall 
draw your attention to a brief analysis of some of the more promi- 



SYMPTOMS OF CEREBRITIS AMD ARACHNITIS. 289 



nent symptoms of this disease ; and here I am anxious to impress 
upon you, that the true mode of studying this subject is not by 
reading the descriptions given by this or that systematic writer, 
but by the careful perusal of monographs, in which the details of 
a great number of cases, occurring under different circumstances, 
are accurately reported. You would be mistaken, indeed, if you 
| were to conclude that you had acquired a thorough knowledge of 
1 the symptoms of phrenitis or arachnitis by reading the description 
! of Culien, Thomas, or Mason Good. The only mode of studying 
| the subject properly is, to take accurate notes of every case which 
you meet with, and to study with care those monographs in which 
| a number of cases, attended by different symptoms, are detailed 
■ with impartiality. 

I would not occupy your attention further with this subject, but 
| that there is much error prevailing with respect to inflammation of 
the brain and its membranes. Persons are in the habit of suppos- 
ing that these symptoms are always constant and well marked, but, 
j the truth is, they are subject to very great varieties. The first 
I symptom, to which I shall call your attention, is pain. This, you 
will recollect, is a prominent symptom of most visceral inflamma- 
tions, where the disease is situated on, or close to, the surface of the 
organ ; but, when it is deep seated, this symptom becomes more or 
less obscure. Now, in a case of arachnitis, we have a double 
source of pain — one depending upon the affections of the serous 
I membrane, the other arising from the circumstance of disease being 
situated on the surface; and hence it is that, in the great majority 
of cases of arachnitis, pain is a constant and prominent symptom. 
Still, if you were to conclude that pain is always present in arach- 
nitis, you would be wrong — for there are many cases on record in 
which it was either partially observed or completely absent. You 
will be greatly assisted in your pathological studies by attending to 
the different results of inflammation of analogous structures, for we 
find that in some of the inflammatory affections of serous mem- 
branes there is little or no pain. We may, for instance, have pleu- 
ritis, pericarditis, and even peritoneal inflammation latent, so far as 
pain is concerned ; nay, many persons have gone so far as to say, 
I that it is only where the muscular tissues of the belly are engaged 
that we have pain in peritonitis. I have seen pericarditis run 
through all its stages without any pain being complained of by the 
patient. Now, if this absence of pain be a matter of no unusual 
occurrence in some inflammatory affections of the pleura, pericar- 
dium, and peritoneum, there is no reason why it may not occur in 
: some cases of arachnitis. Still, it must be acknowledged that pain 
' is one of the most remarkable and constant symptoms of arachnitis, 
i and that, of all the serous membranes, the arachnoid seems to be 
i endowed with the greatest sensibility. 

We might inquire, here, whether the pain of cerebral inflamma- 
I tion be significant of any particular lesion of the brain. I believe 
| that upon this point the state of our knowledge is very unsatisfac- 



290 



STOKES'S THEORY AND PRACTICE. 



tory. Pain as a symptom of cerebral inflammation, occurs in very 1 
different cases. We may have it in connection with disease of the 
superior, lateral, or inferior parts of the brain ; we may have it in 
cases where the result of the disease is a serous, hemorrhagic, or 
purulent effusion. The rule, then, to be borne in mind is this : 
first, that it is present in the great majority of cases of arachnitis ; ; 
next, that it may accompany many different lesions; thirdly, that 
it may be absent ; and lastly, that, with the same lesions, we may 
have pain in one case and absence of it in the other. 

The next subject for inquiry is, does the seat of pain generally 
point out the seat of inflammation 1 Andral distinctly affirms that ' 
it does not. In some cases, pain of the frontal region has been 
found to accompany disease of the ventricles, and pain in one side : 
of the head, an affection of the arachnoid covering of both hemi- 1 
spheres. We see the same thing occurring in the case of other 
serous membranes. Thus, in the pleuritic inflammation of phthisis, 
pain is very seldom felt in the situation of the disease, but generally 1 
lower down ; and I have seen some cases in which pain has been J 
complained of only in the sound side. I recollect a case of very 
extensive pneumonia, in which the patient complained only of some 1 
pain in the region of the kidney and small of the back. 

The pain which accompanies arachnitis generally sets in at an 
early period of the disease, and is characterized by great intensity — 
two circumstances in which it resembles the pain of pleuritis. In 
most cases, it is found that anything that impedes or oppresses the 
circulation of the brain increases this pain ; and hence it is that j 
some practitioners are led to think, that, if pain of the head be 
relieved by pressure, it cannot be inflammatory. Now, I wish to 
call your attention to this point, because, in some cases where evi- ' 
dent marks of arachnitis were found after death, it was observed i 
that during life the pain of the head was relieved by pressure. 
The patients have been found with a bandage tied firmly round the j 
head, from which they experienced decided relief, and yet a post ' 
mortem examination gave unequivocal proof of the existence of 
arachnitis. So far, then, as these cases go, it appears that the mere 1 
fact of pain being relieved by pressure does not prove that it is j 
unconnected with an inflammatory cause. The pain, too, of an 
arachnitis may be intermittent, and continue to exhibit this charac- ' 
ter even for a considerable length of time. I have seen many 
instances of this in children, where the little patient was seized . 
with acute pain of the head at a particular time of the day, which, ■ 
after a few hours' duration, subsided, and then returned again the 
next day precisely the same hour, and continued in this way for 
several weeks, until at length his friends were surprised by the 
unexpected supervention of coma, convulsions, or blindness. I j 
knew two cases of this kind in which the intermittent character of ] 
the pain was so prominent as to engross the practitioner's whole I 
attention ; so that the real nature of the affection was overlooked, 
and bark prescribed. I have now witnessed three or four of these i 



SYMPTOMS OF CEREBRITIS AND ARACHNITIS. 291 

regular quotidian attacks of pain in children, which, after continu- 
ing for days and even weeks, were suddenly followed by perfect 
blindness — in some cases with, and in others without coma. 

You might here ask, whether pain is to be considered as a diag- 
nostic of arachnitis ? I cannot say it is. We constantly meet with 
severe pain of the head without arachnitis, and every one knows 
| that the headache of fever is by no means an indication of inflam- 
I mation of the brain. In many cases of hysteria, the headache and 
; determination of blood to the head are violent, and yet unconnected 
. with inflammatory action. I know a young lady who is frequently 
j attacked with most agonizing headache, accompanied by violent 
throbbing of the carotids and great heat of the face and scalp. Yet, 
| in this case it is plain that the pain cannot be inflammatory, for she 
■ has been subject to these attacks once or twice a week for the last 
i six years, and yet continues otherwise in a state of good health, 
i If her disease were to be measured by the violence of the pain and 
determination of blood to the head, it would be natural to expect 
that death would have long ago put a period to her suffering?. 
This is another proof of the truth of the opinion, that there is no 
single pathognomonic symptom of disease. Bear this in mind. I 
might go farther, and say, that, whether we looked to symptoms or 
to signs, the rule was the same. The man who merely looks to a 
| single sign or symptom will frequently err ; it is only from the 
i whole group of signs and symptoms presented by a disease that we 
| can arrive at any accurate diagnosis. 

I The state of the eye, in cases of arachnitis particularly, has 
attracted much attention. On this subject much valuable informa- 
tion has been obtained by the laborious investigations of Andral, of 

I which I shall give an abstract. He states that the phenomena of 

! the eye, in cases of cerebral inflammation, may be reduced to three 
classes ; its motions, the various conditions of the pupil, and the 
state of vision. With respect to the first of these, it may be ob- 
served that in some cases we find the eyeball in constant motion ; 
in others, it is quite fixed ; while in others the balance of muscular 
power is lost, and there is a constant tendency to strabismus of one 
eye or both. Of all these varieties in the state of motion, the last 

j appears to be the most valuable, so far as the diagnosis of arachnitis 
is concerned. By many persons this strabismus is looked upon as 
a sign that effusion has taken place, and that the disease has reached 
its incurable stage ; a position which I am inclined to doubt, from 
having seen cases recover in which this symptom was present. 
However, Andral looks upon strabismus as a very valuable sign, 
and thinks that, of all the lesions of motion of the eye, it is the 

I most important with respect to the diagnosis of arachnitis of the 
ventricles. With respect to the condition of the pupil, it is stated 

i in books that in the early stage you have a contracted, and in the 

| advanced a dilated pupil, and that the latter condition signifies that 
effusion into the brain has taken place. Now, the truth is that 
this statement must be received with great caution, and as admit- 



292 



STOKES'S THEORY AND PRACTICE. 



ting of numerous exceptions ; for it has been established that the 
same lesions of the brain are sometimes accompanied by very dif- 
ferent conditions of the pupil, and vice versa. Parent and Martinet, 
who have investigated the subject carefully, are the best authorities 
on this point, and I shall give a brief abstract of their experience. 
In cases where both pupils were dilated, they observed that in some 
there was effusion into one of the ventricles, in others, into both. 
In cases where there was no dilatation, they observed that in some 
there was serous or purulent effusion under the arachnoid, while 
in others, in which there was no effusion whatever, the pupil was 
dilated. Lastly, it was found that in some cases, where only one 
pupil was dilated, there was effusion into both sides of the brain. 
You might here ask, whether effusion into the substance, or on the 
surface of one side of the brain, is connected with a dilated condi- 
tion of pupil 1 In reply to this, it may be stated that effusion into 
the substance — not of one, but of both hemispheres — has been 
linown to be accompanied by a contracted state of the pupil to the 
last. You may also have one pupil contracted and the other 
dilated ; nay, you may have an alteration of these conditions — the 
right being dilated to-day, the left to-morrow. The mere circum- 
stance, then, of dilatation or contraction of the pupil is no sign, 
when taken by itself, as to the seat or even the existence of effu- 
sion ; for you may have either condition with or without effusion, 
and you may have dilatation of the pupil of one eye with an effu- 
sion into both sides of the brain. As a general rule, however, it 
seems to be made out, that, in most cases of cerebral inflammation 
terminating in effusion, there is often, towards the advanced period 
of the disease, some dilatation of pupil, and that this condition 
generally marks the occurrence of effusion. 

With respect to the affections of the function of vision, there are 
great varieties. Some patients have double vision — others see 
sparks of fire, or muscas volitantes. There are many other pheno- 
mena of the kind, causing a great variety in the symptoms; and 
this variety is found to depend more on the susceptibility of the 
brain to irritation, rather than on the mere existence of irritation 
of the serous membrane investing it. The same rule applies to all 
cases of serous inflammation, the phenomena of inflammation | 
varying according to the susceptibility of the organ which the 
inflamed membrane covers. Thus, for instance, one patient will [ 
have pericarditis with palpitations of the . heart* another without! 
them; their occurrence or non-occurrence merely showing that 
the heart is more or less susceptible to irritation. So it is with 
respect to the brain, and the symptoms of deranged vision are 
connected with the greater or less susceptibility of the organ, 
which we know varies very considerably in different persons. 
This remark applies to all the forms, and, I believe, all the pheno- 
mena of meningitis. 

In acute disease of the brain and its membranes, we often have 
convulsions and paralysis, and in these symptoms also we find 



I 



SYMPTOMS OF CEREBRITIS AND ARACHNITIS. 293 

i great variations: in some we have convulsions of one side, in some 
! of both, in others we have paralysis, but scarcely any convulsions. 
! The same remark also applies to these symptoms, as to some 
I already mentioned — namely, that we cannot from them alone form 
| an accurate estimate of the situation or amount of disease. You 
j may have convulsions and paralysis of various kinds with the same 
I kind of lesion, and you may have a variety of lesions with the same 
; paralysis and convulsions. The only thing that appears to be 
pretty well established is this — that, generally speaking, in cases 
j where the right side of the brain is engaged, you have convulsions 
and paralysis of the left side of the body, and vice versa. 

Before I proceed to speak of delirium, I think it necessary to say 
; a few words more with respect to convulsions, as I find Andral has 
■ not touched on a point to which I beg to call your attention. The 
i occurrence of convulsions in a child, labouring under symptoms of 
inflammation of the brain, is always looked upon as formidable; 
and indeed it is natural that convulsions, to persons unacquainted 
! with pathology, should seem to point out a great intensity of dis- 
ease. I have, however, been long of opinion that convulsions 
occurring during the existence of hydrocephalus in children, or of 
, meningitis in adults, are not so dangerous as persons generally 
think. I will even go so far as to say, that the worst cases I have 
seen, in which a cure was effected, were those in which there were 
the greatest and most violent convulsions; and that, in most of the 
i cases which appeared to go on without any benefit from medicine, 
there were scarcely any. I am of opinion that convulsions are 
often of benefit by giving relief to the brain. This statement must 
I appear somewhat paradoxical, but I trust I shall be able to prove 
to you that it has some foundation in truth. Broussais has taught 
that there appear to be two great modes of reaction in the economy, 
to obviate the effects of abnormal stimulation applied to important 
viscera — fever and convulsions. The irritations which attack the 
cerebro-spinal system maybe relieved by convulsions ; those which 
attack the viscera may be relieved by fever and secretion. This 
! doctrine, I think, might be expressed otherwise. The irritations of 
organs are often relieved by an increase, w T ith or without altera- 
tion, of their secretions. But, as we have used the term secretion 
to express something material, we apply the proposition merely to 
the viscera of organic life. Now, it may also be extended to the 
organs of animal life. A violent expenditure of nervous power 
j may relieve the brain or spinal cord, and delirium and convulsions 
; prevent or modify organic changes, just as secretion from the lung 
I or bowels may prevent ulceration. 

I have said that the brain might be relieved by convulsions. Let 
! us, holding this assertion in view, compare the phenomena and 
j results of apoplexy with those of epilepsy. In the first place, it is 
I to be remarked that the earlier phenomena of both are the same — 
j namely, an active congestion of the vessels of the head. Any one 
i who has seen the first stage of both must admit this. But let us 

26 



I 



294 



STOKES'S THEORY AND PRACTICE. 



follow them up through their remaining stages. In the one, we have 
the determination to the head, followed by convulsions more or less 
violent and protracted, which, however, subside after some time, 
and the patient gets well; in the other, there is either death from 
the violent determination of blood and probable effusion, or, if the 
patient recovers, there is very often paralysis, showing that injury 
has been done to the substance of the brain. Now, here we per- 
ceive that the case of determination without convulsions is that in 
which there is either death or recovery with paralysis ; there are 
no such bad consequences to be dreaded where the determination 
to the head is followed by convulsive fits. In apoplexy we have 
congestion followed by death, or recovery with paralysis; in 
epilepsy we have congestion, convulsions, and relief. It is plain 
that, if we admit the identity of the phenomena in the early periods 
of both, we must then also admit that the only cause of relief we 
can ascertain is convulsions. This idea of the subject will explain \ 
how it is that a man may continue for years subject to repeated i 
attacks of cerebral congestion, and yet to continue to enjoy tole- § 
rable health. It will also explain why it is unnecessary and some- 
times even dangerous to bleed in epilepsy. It also shows why it is 1 
so often unaccompanied by paralysis, because the brain is relieved ; 
by the expenditure of its nervous energy on the muscular system. > 
I think we should generally look upon the occurrence of convuU b 
sions, in a case of cerebro-spinal irritation, in the light of an attempt 
at a crisis made by nature itself. What is a crisis'? An organ la- p 
bouring under irritation is suddenly relieved by a new process ? 
taking place, either in itself or in some other part ; and when we p 
come to examine what these modes of relief are, we find them to || 
consist in the occurrence of supersecretion, hemorrhage, exanlhe- bj 
matous eruptions on the surface, or convulsions. There is no doubt 
that, when we look to the results of the sudden supervention of a i| 
copious secretion in an inflammatory affection of any secreting 
organ, the source of relief is manifest. If we take two cases of 
hepatitis or bronchitis — one attended with copious secretion, the p 
other without any secretion at all — it will be easy to conceive how jl 
much more dangerous the latter is, and how much more difficult to | 
manage. Now, if we consider the brain in this point of view, we ; 
find that it is not a secreting organ, in the ordinary acceptation, and 
that the only mode in which it can relieve itself is by the expendi* jc 
ture of its excess of nervous energy on the muscular system, or by : 
the same expenditure of mental energy, as in the case of high de- ' 
lirium. I think we might fairly draw an analogy between this i 
mode of relief and that which, in other diseases, is the result of 
hemorrhage or secretion. One fact, at all events, appears certain, , 
that in two most remarkable cases of different diseases — each, how- 
ever, characterized by the same phenomena in the early stage, 
namely, active determination to the head — we find that the case 
which turns out favourably is that in which convulsions occur 
(namely, epilepsy) ; while in apoplexy, where these symptoms areSj 
absent, we have either death or recovery with paralysis. 

| 



SYMPTOMS OF CEKEBRITIS AND ARACHNITIS. 295 



If this opinion be well grounded, it would militate strongly against 
j the practice of checking the convulsions of meningitis by opiates. 
I I feel convinced that this practice is wrong and dangerous ; its 
effects may be as injurious as the arresting the reactions by astrin- 
gents in a case of acute inflammation. There are two ways in 
which we can explain its bad effects. In the first place, opiates 
| prove detrimental by checking the convulsions, which appear to be 
J a mode of relief adopted by nature ; and, next, they must do mis- 
I chief from their well-known tendency to add to the existing cere- 
I bral congestion. I have now seen a good many cases of meningeal 
. inflammation in which convulsions took place, and where opiates 
! were employed to remove them, and feel compelled to state that the 
j opium has certainly relieved the convulsions, but the patients have 
! afterwards fallen into a state of profound coma, from which they 
i never recovered. I have witnessed this so often, that I should not 
discharge my duty properly, did I not warn you against the employ- 
ment of opium in arachnitis. The same rule most commonly holds 
I good in cases of visceral inflammation, where an organ is in a state 
! of irritation, and has its secretions suppressed. Here also opium, 
by arresting secretion and increasing congestion, will be productive 
of bad effects. I allude here particularly to the treatment of pneu- 
monia by opium, as recommended by Dr. Armstrong, who lays 
great stress upon its use in full doses after having premised a single 
bleeding. I have had some experience of this mode of treatment, 
| and find that the effect of the opium is not to remove, but to con- 
vert a manifest into a latent disease. I have seen the pain, dyspnoea, 
and cough subside, but the fever continued, and the destructive 
| process of the lung went on as usual. This is the result of my 
experience. 

I shall now make a few observations on the occurrence of deli- 
rium in disease of the brain. In one of my former lectures I al- 
luded to the important fact, that, in the majority of cases of menin- 
gitis, where delirium was present, there was inflammation of the 
convexity of the brain. I stated also, that, when inflammation at- 
tacked the base of the brain, we might have it going through all its 
stages without delirium, and pointed out the importance of this in 
! favour of the phrenological doctrines. Andral admits the occur- 
| rence of delirium in case of inflammation on the convexity of the 
| brain, but his reasoning upon this subject appears to me to be incon- 
clusive. He divides affections of the convexity of the brain into 
those which are characterized by delirium through their whole course, 
; and those in which coma is the most remarkable feature ; and seems 
j to think that, where coma is the most remarkable symptom, the re- 
i suits of the case are unfavourable to phrenology. But we shall find, on 
i examining these cases, that, in many of them where coma was the 
t predominant feature, there had been delirium in the commence- 
| ment. He gives the details of thirty-nine cases accompanied by 
delirium all through, in thirty-six of which there was disease of 
the convexity of the brain, either simple or complicated with arach- 



296 



STOKES'S THEORY AND PRACTICE. 



nitis. As far, then, as his first set of cases go, they are in favour 
of the opinion that inflammation of the convexity of the brain is 
most commonly attended by delirium. It appears, also, that in those 
cases in which coma was the most remarkable symptom there was 
more or less delirium in the commencement ; so that, whether we 
take the cases in which there was delirium all through, or those in 
which there was coma, the conclusions appear to be in favour of 
the doctrines of phrenology. 

I shall now proceed to make some remarks on the phenomena of 
organic life in cases of cerebral inflammation. In the first place, 
with respect to the tongue, w r e find that in simple arachnitis it is 
but slightly affected ; there may be some trifling degree of foulness, 
or it may be quite clean and moist. You will observe the value of 
this, as connected with the diagnosis of irritation of the brain from 
disease of the digestive system. There are many cases of irritation 
of the digestive system putting on the semblance of hydrocephalus 
to such a degree as even to mislead an experienced practitioner. 
JNow, if it be true that in simple arachnitis the tongue remains 
clean, it furnishes us with very material information, as, under such 
circumstances, our attention will be directed to the true seat of dis- 
ease. Andral says, that in some cases of arachnitis he has found 
the tongue red, or dry, or foul, but that at the same time there was 
disease of the digestive system. The majority of his cases, how- 
ever, were simple, and exhibited no marks of an affection of the 
tongue or digestive system. 

There is one more symptom on which I wish to offer a few 
observations, and that is the occurrence of vomiting in the hydro- 
cephalus of children. In all cases where there is obstinate vomit- 
ing, particularly in children, you should have your suspicions 
roused, and look carefully to the state of the head. Vomiting is a ; 
symptom which occurs in many cases of arachnitis ; in some it is [ 
slight, in others more constant, while in a third class it is harassing, 
incessant, and produced by swallowing the most unirritating sub- 
stances. The nature of the fluid rejected from the stomach is 
various — being sometimes bilious, sometimes mucous, sometimes I 
only consisting of what has been recently drunk. In some of these 
cases you will find the symptoms of incessant vomiting, unaccom- 
panied by pain of the stomach, tenderness of the epigastrium, or 
any other sign of disease of the digestive system. I have even 
seen it coexisting with a good appetite. Many persons have been 
lost by such cases having been mistaken for disease of the digestive 
system, the practitioner being ignorant that vomiting was here only 
symptomatic of disease of the brain, No matter what the situation 
of the meningitis may be, it is now established that you may have 
vomiting as a common symptom. I recollect the case of a delicate 
child, about seven years of age, who laboured for some time under 
catarrhal fever, on the subsidence of which she got an attack of 
vomiting, which came on at different times in the day, but without 
headache, delirium, or intolerance of light. This vomiting con- 
tinued from day to day ; and, at the end of the week, the pupils 



TREATMENT OF HYDROCEPHALUS. 297 



became suddenly dilated, and coma set in, under which she died. 
There is one very remarkable circumstance connected with this 
subject, with which I am anxious you should be acquainted. Where 
this incessant vomiting is present, you will have the other symp- 
toms of meningitis more or less latent This illustrates a law 
I before alluded to, that, where the phenomena which are the result 
j of sympathy with an affected organ are very prominent, those which 
; characterize the disease of the organ itself are more or less latent. 
I If we take the reverse of the former case, and consider a case of 
| gastric disease, we know that the irritation of the stomach will pro- 
duce violent cerebral symptoms, and that here also the same law is 
| exemplified — for we shall have absence of pain, tenderness, and 
vomiting. The great value of this rule is, that a knowledge of it 
I will put you on your guard, and that the mere absence of the pecu- 
i liar symptoms of an affection of an organ possessing extensive sym- 
pathies, should not lead you to conclude that there was no disease 
of that organ. In some remarkable cases of gastritis, the principal 
j symptoms observed were convulsions and delirium ; there was no 
vomiting or thirst, very little pain on pressure, and nothing remark- 
able in the condition of the tongue. The same latency of inflam- 
, matory disease is frequently seen in cases of delirium tremens. 

With respect to respiration and the state of the pulse in menin- 
i gitis, there is very little to be said. You may have meningeal 
| inflammation with every variety of pulse — strong, weak, full, rapid, 
I slow, or intermittent. Generally speaking, the pulse is, towards 
the close of the disease, feeble and intermitting, but you may have 
the disease running through all its stages without any peculiarity 
in the character of the pulse. Respiration seems to be very little 
affected, and this would appear to favour the opinions of Sir Charles 
Bell. There is no doubt, at least, that the sympathy of the brain 
with the respiratory system is much weaker than with the digestive. 

TREATMENT OF HYDROCEPHALUS. 

I shall occupy your time but very briefly on the treatment of the 
I hydrocephalus of children, as it appears to me to be a disease in 
| which, of all others, the principles of treatment are most simple, 
j The old idea of this affection was, that it was a species of dropsy, 
depending on the relaxed state of the cerebral vessels, and hence 
the term hydrocephalus. Modern pathology has shown that the 
occurrence of serous effusion is a mere accidental circumstance, as 
it is present in one case of arachnitis and absent in another. When 
it does occur, however, it is the result of inflammatory disease, 
| and it is to the prevention and cure of this that the practitioner 
must direct his attention.* With the symptoms of this disease I 

j * [Th3 opinions advanced by former writers, that the chief predisposing 1 cause 
I of hydrocephalus is a scrofulous habit, and that when scrofula attacks the mem- 
{ branes of the brain, its symptoms are usually those of acute hydrocephalus (Cyclo 
\ pedia of Practical Medicine), have been fully confirmed by the experimental 
| observations of Drs, Gerhard and Rufz, made in the Childrens' Hospital at Paris, 

26* 



298 



STOKES'S THEORY AND PRACTICE. 



shall not take up your time, as you will find them sufficiently 
detailed in books ; but, with respect to treatment, I shall say that 
hydrocephalus is a disease much more under the influence of treat- 
ment than persons generally think. It is said that, when once 
effusion has taken place, the case is hopeless, and nothing can be 
done. This remark appears to me to be unnecessary, for there is 
no symptom from which you can venture to assert that effusion 
have set in. . You may, from the inflammatory state of the brain, 
have delirium, coma, deafness, blindness, and paralysis, without 
any effusion of serum; and in many cases life has been saved, even 
after the appearance of all these symptoms. 

This term effusion is one of the bugbears of medicine. Many 
patients are lost from the prevalence of false ideas connected with 
this subject; for, as soon as effusion is supposed to have set in, the 
efforts of the practitioner are given up. Hundreds of patients die 
of bronchitis and pneumonia, in whom life might be saved if the 
symptoms of effusion had been treated for those of inflammation ; 
and so it is with respect to the brain. This effusion is not the dis- 
ease — it is not even a constant result of the disease. We have no 
certain means of ascertaining its existence ; and we know, that, by i 
a persistence in antiphlogistic treatment, life may be often saved, 
even after all the supposed symptoms have occurred. 

Take this with you as a rule in medicine : always to keep your 
eye more upon the causes than the effects of disease. 

The treatment of hydrocephalus in the child should always be 
■active, and conducted on the same principles as those of general 
encephalitis in the adult. Shaving the head, bleeding when prac- 
ticable, repeated leeching, cold affusion, calomel^ and jnirgatives — 

in the period between 1832 and 1834. These gentlemen " state, and prove by rigid 
deductions, that the acute meningitis, or acute hydrocephalus, if the older term be 
preserved, is really a tuberculous disease ; it is inflammatory in its direct action, and 
the tuberculous granulations are either formed already in the brain and followed 
by the acute inflammation, or they are secreted by the inflammatory process, the ves- 
sels throwing outat thesame time lymph and tuberculous matter. Thisdiseaseis by 
far the most frequent of the acute inflammatory disorders of the brain in children, 
especially from the age of two years to that of puberty ; and we therefore separate 
this disease from other acute affections of the brain, laying stress upon the pecu- 
liar nature of the disease as connected with the tuberculous secretion, and looking i 
upon the affection as one and the same, whether there is or is not an effusion of 
serum into the ventricles. This view, then, of the pathology of the disease, ren- 
ders the term hydrocephalus obviously improper; and it was this which induced 
us to substitute that of tuberculous meningitis, which has since come into general 
use."— Dr. Gerhard on the History of Tuberculous Meningitis — Medical 
Examiner, Vol. Ill, No. 19. 

Dr. Gerhard published his original observations in 1834 in the American 
Journal of Medical Science ; and subsequently in 1835, a memoir on the acute 
hydrocephalus of adults, "proving that it was identical with the tuberculous 
meningitis of children, and depended upon the same cause. This was the 
first memoir which proved that the disease was as distinctly characterized in 
adults as in children, and that the anatomical lesion was in both cases independent 
of the effusion of serum into the ventricles of the brain."— Dr. G. nt supra. The 
ultimate cause of the disease is, Dr. Gerhard thinks, the lymphatic temperament ; 
or, as other writers have termed it more vaguely, a tuberculous diathesis.— B.} 



TREATMENT OF HYDROCEPHALUS. 



299 



these are the great measures upon which we are to rely for success. 
It is satisfactory, too, to reflect, that many cases have been saved by 
the prompt and steady adoption of this simple mode of treatment.* 

OF INTERNAL REMEDIES. 

The use of mercury seems to be that on which you should most 
rely. Some of the most singular recoveries have occurred after 
ptyalism has been produced. Let me remind you, however, that 
the rules connected with this mode of treatment, which I pointed 
| out in speaking of hepatitis, apply equally in this case. There is 
a terrible consequence of mercurial action in the lymphatic temper- 
| ament, with which you should be acquainted ; I allude to violent 
and destructive inflammation of the soft parts of the mouth and 
I face, which has got the name of the mercurial cancrum oris. An 
| oedematous inflammation of the cheeks, lips, and tongue, takes 
< place, and, if not checked, rapidly runs on to extensive ulceration. 

I have seen one cheek, half of the nose, the lower eyelid, and the 
| opposite angle of the mouth, utterly destroyed, in a case where but 
five grains of calomel were used. This drawing represents the 
disease, after a frightful perforation of the cheek. In this case the 
quantity used was nine grains. I have .seen the disease from the 
I use of so small a quantity as a grain and a half of calomel ! These 
i fact show that there is a state of the constitution in which a minute 
I dose of calomel may have terrible effects. The same, too, may 
arise from the externa] use of mercury. I recollect the case of a 
young woman in the Meath Hospital, whose head was rubbed with 
one dram only of mercurial ointment, for the purpose of destroying 
vermin. She was attacked, and with difficulty saved. 

The disease may also come on suddenly in a patient who has 
been for some time using mercury in considerable doses ; but this 
is the rarest case. 

You recognise this disease by the sudden supervention of great 
swelling of the lips and cheeks, so as to completely alter the expres- 
sion. The tongue is also swollen. All these parts are hot and 
tender to pressure. The breath is fetid, and the internal surface 
of the mouth excoriated, and often covered here and there with 
! patches of lymph. At other times we have a circumscribed cede- 
) matous swelling, occupying the centre of the cheek, which runs on 

| * [If leeches cannot be procured, cups to the nucha and above the mastoid pro- 
; cesses, or on the spine, between the shoulders, will answer. After suitable deple- 
tion, and when we deem the period proper for counter-irritation, a large blister 
| to the neck or between the thighs, has been seen by Billard (Diseases of Infants, 
| Stewart's Translation), to be followed with success. Some stress, and deservedly, 
is laid by Dr. Mills of Dublin, on the use of the tartar emetic ointment, applied 
i to the vertex or occiput, of such strength and with such frequency as soon to 
j cause a pustular eruption and purulent discharge, which will be found especially 
I useful in cases of repelled scabies, preceding the disease in question. In the acute 
| form we cannot expect anything from a caustic issue on the vertex, as recom- 
j mended by some. " Mercury, to be effectual, must," Dr. Chapman thinks, "be 
j applied in a very resolute manner," internally and externally.— *B.] 



300 



STOKES'S THEORY AND PRACTICE. 



to ulceration ; but most commonly the ulceration of the external 
parts begins at the depending angle of the mouth. 

In a case of this kind, if you are called before ulceration has 
taken place, I believe you can often save your patient, and prevent 
destruction of the face. Treat the disease as a violent inflam- 
mation ; use repeated leeching, poulticing, and the warm bath. 
While you do this, you must keep up your patient 9 s strength by light 
nourishment and wine. Apply to the internal ulceration the mel 
seruginis, the nitrate of silver, or the chloride of soda. I have now 
saved many cases by bold and repeated leeching. I remember 
one case of a man in which ninety leeches were used ; he recovered 
perfectly. 

In the treatment of this affection, it is of the utmost consequence 
to attend to the position of the patient. By keeping him as much 
as possible upright, or by preventing him leaning constantly on one 
side, we do much to prevent the occurrence of the ulceration of the 
angle of the mouth. 

As far as I can see, hydrocephalus, when taken in time, is a very 
manageable disease; and there is only one case in which it is diffi- 
cult to treat, and that is where the cerebral affection is accompanied 
by symptoms of gastro-enteric disease. In several cases of hydro- 
cephalus, this complication certainly exists; and you have first 
symptoms of disease of the digestive tube, and then of the head. 
Such cases as these are involved in great difficulty, and in their 
treatment you run the hazard of falling into a twofold mistake. 
The first is your acting on the supposition that the disease of the 
head is only sympathetic, and that it will subside as soon as the 
abdominal symptoms are removed ; the other is occupying your 
attention exclusively with the head. Now, there is one rule with 
respect to this, which I think will serve to guide you through many 
difficulties, and this is, never to neglect the head. Though you 
have first an affection of the digestive system, and then of the head, 
it is better (even though the symptoms of the latter still continue) 
to pay attention to the head. You can do this at the same time 
that you are attentive to the condition of the digestive organs. 
Another rule is, that the cases of disease in which the purgative 
plan does not answer are generally those in which there is primary 
inflammation of the digestive tube. Dr. Cheyne, in speaking of the 
treatment of hydrocephalus, says, that some cases are benefited by 
purgatives, others not ; and that the latter are those in which there 
is disease of the intestinal canal. In such cases you will not irri- 
tate the bowels, or add to the existing inflammation by purgatives. 
Let the bowels be kept open by enemata, and direct your attention 
immediately to the head. Children with largely developed heads, 
and of a strumous diathesis, are very subject to this disease; and 
I feel convinced that the present rage for the early mental educa- 
tion of children has a strong tendency to produce it in subjects of 
this description. I believe there are many cases of fatal hydro- 
cephalus from which the poor victims would have escaped, but for 



APOPLEXY. 



301 



the pernicious efforts of the parents to make them literary prodigies. 
I I have observed many cases of this kind among the children of 
I persons who, having been originally situated in an humble sphere, 

and deprived of the benefits of education, accumulate wealth ; and 
i then, feeling in their new condition the want of education, are 
! anxious to communicate it to their offspring; and, with that view, 
j have them educated with too much care, and from too early a period. 
I The child is constantly kept at his books — his little mind is per- 
| petually tasked — a degree of cerebral excitement is kept up — and, 
! while he is delighting his gratified parents with the manifestations 
I of a precocious intellect, his health is neglected, and the seeds of 
; disease are insensibly sown. One of the most ordinary conse- 
i quences of this early application of the mental powers is hydro- 
| cephalus. These little creatures, too, have a congenital disposition 
! to disease of the brain, for they have generally large heads. Such 
: cases are examples of the results of an arrest of development. A 
I relative condition of head exists similar to that which occurs dur- 
1 ing foetal life, and this is always accompanied by a remarkable 
I susceptibility to inflammation. This peculiar development of head 

also produces a precocious state of intellect, which is increased by 
| the pernicious habit of obliging children to study at too early an 

age. Where you meet with children suffering under these circum- 
I stances, you will not discharge your duty properly if you do not 
I point out to the parents the mischievous tendency of their conduct. 
I In such cases as these it may be justly said that ignorance is bliss. 



LECTURE XXVIII. 

Apoplexy — Cerebritis and meningitis — Definition of apoplexy — Simple or nervous 
apoplexy without disorganization — Complicated with other diseases — Congestive or 
serous apoplexy — Dr. Abercrombie's opinions — Apoplexy with extravasation — Sites 
of extravasation — Absorption of clot — Apoplexy in children. 

We were occupied at our last meeting in considering some of 
j the most prominent symptoms of meningeal inflammation ; and I 
i beg of you to recollect, that all these symptoms, with the exception 
I of pain, are those which ordinarily characterize inflammation of the 
i substance of the brain itself, and are to be explained by referring 
! them to some lesion in the functions of that organ. It appears, 
: then, that the symptoms of meningitis, with the exception of pain, 
are symptoms of an affection of the brain itself; and this is a point 
i which you must always bear in mind, when you agitate the ques- 
i tion as to the possibility of making a diagnosis between meningitis 
j and encephalitis. We have a set of symptoms characterizing 
I meningeal inflammation, the majority of which belong to irritation 
j of the brain itself ; and we find that these may exist with or with- 
out any perceptible alteration in the cerebral substance. Now, in 



i 



j 



302 



STOKES'S THEORY AND PRACTICE. 



cases where you suppose the existence of meningeal inflammation, 
and find these symptoms present, it would be venturing too much 
to assert that there was no complication with organic disease of the 
brain ; and, therefore, we must conclude that, in most cases, it is 
nearly impossible to distinguish between inflammation of the sub- 
stance of the brain and of its membranes. 

In speaking of the more important symptoms of cerebral inflam- 
mation, I alluded particularly to convulsions, and stated, that, as 
far as my observations went, this symptom, formidable as it may 
appear, is not in reality so unfavourable as it is generally thought 
to be. In fact, there are many cases of affections of the brain, 
accompanied by convulsions, in which the danger is by no means 
so great as in others of a different description ; and many of the 
worst cases are those in which convulsions are absent, or only 
trifling. I think we may look upon convulsion as being more or 
less a source of relief to the brain, when labouring under the excite- 
ment of irritation or inflammatory disease. You are all aware, that 
one of the great functions of the brain is to regulate and control the 
motions of the muscular system. If a man exercises his limbs 
violently for some time, he becomes tired and exhausted ; he can- 
not pursue the same exercise any longer, for in addition to what- 
ever the muscular system may suffer, there has been a great 
expenditure of nervous energy ; and if he should attempt to keep 
up the same exertions, such a degree of muscular and nervous 
debility is superinduced that syncope is the consequence. Now, 
the expenditure of energy produced by the supply of nervous power 
to the muscles, seems to bear a strong analogy to the secretory dis- 
charges from other viscera. In the case of irritation or inflamma- 
tory affections of other organs, you are all aware that there is 
nothing which gives such speedy and effectual relief as supersecre- 
tion, or an increased action of the secreting vessels of the affected 
organ. Now, if we look upon the expenditure of nervous energy 
in the same light (and I see no reason why we should not), we can 
easily conceive why it is that convulsions relieve the irritation of 
an over-excited brain. I drew your attention strongly, at my last 
lecture, to the curious and important fact, that if we compare 
apoplexy and epilepsy, with respect to the danger and the chance 
of disorganization attendant on each, we shall find the danger is 
infinitely greater, and the chances of organic change more numer- 
ous, in the former than in the latter. In epilepsy, where the con- 
vulsions are violent, we seldom have a fatal termination of the fit, 
and there is rarely lesion of the substance of the brain, until the 
disease has lasted for a great length of time. This is not the case 
in apoplexy. Here, as I have already stated, we have two cases 
of active determination to the head : in one case there are no con- 
vulsions, and we frequently find the result to be death, or extravasa- 
tion with paralysis and slow convalescence ; in the other, we have 
violent convulsions, followed by rapid recovery and no disorganiza- 
tion. From this, it would seem reasonable to conclude, that con- 



APOPLEXY. 



303 



vulsions are a mode of relieving the brain, adopted by nature, and 
that their occurrence in hydrocephalus should not be looked upon 
as unfavourable. Now, if this be true, it must strike you, that 
nothing can be more dangerous and improper than to take any 
steps to control an attack of convulsion during the prevalence 
of hydrocephalic symptoms. The true mode of treating them is 
to adopt measures calculated to relieve irritation of the brain, and 
not hazard the patient's safety by following the ordinary but mis- 
chievous mode of attempting to control the salutary efforts of 
nature. I allude here particularly to the practice of administering 
opiates and antispasmodics, a practice which I firmly believe to be 
fraught with danger. 

We have to-day to consider another form of cerebral disease, 
scarcely less important than those with which we have been 
hitherto engaged. In all the former instances, we find the deter- 
mination of blood to the brain followed by that organic change 
which we term inflammation. But we may have accumulations 
of blood in the brain, unaccompanied by inflammation, and this 
brings us to the consideration of apoplectic disease. The term 
apoplexy, as I suppose you all know, is derived from a Greek word, 
signifying a stroke or blow. It is a term which, in the present state 
of medicine, has been very frequently abused, or at least employed 
in very different senses, and hence the many erroneous opinions 
respecting it. The true meaning of the term expresses an altera- 
tion of the phenomena of the life of relation, that is, of the functions 
of the cerebro-spinal system. In taking a view of the nature of 
this alteration, we find that the attack generally comes on in a 
sudden manner, and that the functions of the brain are partially or 
completely suspended. You are aware that the manifest pheno- 
mena of the life of relation are those which belong to sensation, 
muscular motion, and the intellect; and that the system of the life 
of relation is composed of the brain, spinal cord, and nerves. Now 
suppose, for example, that a man gets an attack of apoplexy, we 
find him paralytic — here is a lesion of the muscular function. We 
find him insensible to external stimulants, he feels no pain — here is 
a lesion of sensation. We may find his sight, hearing, taste, smell, 
and touch, are injured ; he lies in a state of insensibility, and is un- 
conscious of everything passing around him — here we have an ex- 
ample of interruption in the performance of the intellectual functions. 
All these phenomena exhibit the various lesions superinduced by an 
attack of apoplexy, in the functions of those organs which subserve 
to the life of relation. 

I have said that the term apoplexy is frequently abused in modern 
medicine. From the circumstance of most cases being accom- 
panied by an effusion of blood on the surface or into the substance 
of the brain, the term has been also applied to sanguineous effusions 
into other organs, and we hear every day of pulmonary and hepatic 
apoplexy; terms implying the extravasation of blood into the sub- 
stance of the lung or liver. The analogy, however, in such cases 



304 



STOKES'S THEORY AND PRACTICE. 



will on examination be found to be coarse, and the application of 
the term loose and improper. Apoplexy, as a cerebral disease, 
may occur w r ith or without effusion ; in either case, the disease, 
quoad the lesion of function, is the same ; but to give the name of 
apoplexy to hemorrhage into the lungs or liver, is improper. The 
term apoplexy should be used only with reference to the brain, and 
applied to a particular train of lesions in the functions of the life of 
relation, occurring with or without an effusion of blood, or even con- 
gestion. When we have effusions of blood into other viscera, we 
may have them unaccompanied by any apparent lesion in the func- 
tions of the organ affected (a circumstance rarely met with in the 
case of the brain) ; and it would be much better to give some other 
name to those hemorrhages into the substance of the liver and 
lungs, than to designate them by one drawn from a loose and im- 
perfect analogy. 

The suspension of the phenomena of the life of relation, complete 
or partial, which constitutes apoplexy, may be connected with any 
of the following pathological conditions. First, great congestion of 
the brain, in which the vascular system of that organ is overloaded, 
but without extravasation of blood or serum ; tiiis is termed the 
congestive apoplexy. In the next place, w 7 e may have this con- 
gested state of the vessels of the brain with an extravasation of 
blood on its surface. To the latter form, the meningeal apoplexy 
has been applied. Thirdly, with an effusion of blood into the sub- 
stance of the brain, which is the most common case, and, lastly, 
we may have complete apoplexy without morbid appearance, or, if 
there be such, quite insufficient to account for the phenomena. A 
man will fall down suddenly, he will lie in a state of insensibility, 
with stertorous breathing, coma, and paralysis, he will die with all 
the symptoms of the worst form of apoplexy, and yet, on dissection, 
the brain may be found, to all appearances, healthy. This is what 
has been termed, by the older authors, the nervous or convulsive 
apoplexy ; of the real nature of which we are still as ignorant as 
we are of the real nature of tetanus, hydrophobia, and other nervous 
diseases unaccompanied by perceptible organic change. 

This is the simple apoplexy of Dr. Abercrombie, of which he 
gives several most important cases, and refers to others related by 
the older authors. You will at once admit that it is not more 
extraordinary that apoplexy should exist without perceptible 
organic change, than mania, tetanus, hydrophobia, and other affec- 
tions. Of the fact there is no doubt. Such cases, indeed, are rare ; 
which, in one sense, may be looked on as a fortunate circumstance. 
But in the progress of other diseases, this nervous coma, or apoplexy, 
is by no means uncommon. Thus there is no symptom more 
common than coma in typhus; and yet, if you examine the head 
after death, you generally either find no lesion at all, or such as 
will not be sufficient to account for the symptoms. The coma, 
which occurs in cases of painters' colic, too, appears to be closely 
connected with this nervous apoplexy. You will recollect an inte- 



APOPLEXY. 



305 



resting clinical experiment I made in the case of a patient with 
| painters' colic, who had profound coma. In this case, I thought it 
! probable that the condition of the brain bore no resemblance to 
I sanguineous apoplexy, because the symptoms of painters' colic are 
| seldom or never accompanied by hyperemia of the nervous or 
I other systems. Under this impression, I prescribed a full opiate, 
| and this not only did not increase the coma, but, on the contrary, 
I produced the very best effect, for the patient was amazingly 
I improved the next morning. I do not so much mean to say, that 
! opium is useful in nervous coma, as that, in this instance at least, 
I the coma was not of the congestive kind. It is not unlikely, too, 
that the coma of jaundice is of the same description, and uncon- 
nected with any decided hypersemia of the brain. I am aware that 
1 in jaundice the coma is supposed by some to depend upon a bilious 
! condition of the blood circulating in the brain; but there are so 
many cases of persons who have laboured under jaundice for years 
without having coma, that we must seek for some other explanation. 
Now, so far as we know of the encephalon in persons who have 
I died of jaundice, it appears that little or no congestion exists ; and 
hence it seems probable that the coma of jaundice is similar to that 
of nervous apoplexy. 

I shall now proceed to the consideration of those forms of 
apoplexy which are connected with changes more or less apparent 
in the circulation of the head, and with which we are, consequently, 
I better acquainted. I have told you that simple congestion of the 
brain may be accompanied by symptoms of apoplexy, or that we may 
have the disease presenting, in additon to this, an effusion of blood 
into, the substance, or on the surface of the brain. The simplest 
idea you can get of the condition of the brain in the congestive 
form, is to consider what its state is in persons who have been 
hanged. These persons have the vessels of the brain loaded with 
blood from the violent interruption of the venous circulation. 
Now, this increase in the quantity of blood circulating in the brain, 
may arise from two causes, one depending on the interruption of 
the venous circulation, the other produced by an increased action 
of the arterial system. Hence in certain cases of disease of the 
heart, where the blood is sent with great force to the head, there is 
a strong predisposition to apoplectic attacks. The kind of disease 
| of the heart, however, which has been found most liable to produce 
this, is not, as you would suppose, Corvisart's active aneurism, but 
simple hypertrophy of the heart, where the cavity of the left ven- 
j tricle continuing the same, its walls are increased in thickness and 
j strength, so that, on the natural quantity of fluid, an increased im- 
I pulse is exercised. Such, at least, is the result of Andral's researches, 
i and there is every reason to place confidence in the accuracy of 
| his conclusion.* 
I 

I * [In addition to the names of Broussais, Andral, and Lallemand, we may cite 
I those of M. M. Bricheteau and Bouillaud, and Dr. Hope, all of whom have pointed out 
I numerous cases of the connexion between hypertrophy of the left ventricle and 

27 



i 

i 



306 



STOKES'S THEORY AND PRACTICE. 



About this congestive apoplexy there appears to have been a 
good deal of misapprehension. You have all heard of the serous 
apoplexy. In this form, it has been supposed that the cause of the 
compression of the brain, and all the other symptoms, is an effusion 
of serum, just as an effusion of serum into the cavity of the pleura 
will produce compression of the lung and dyspnoea. The idea 
which has been generally entertained is, that the effusion of serum 
is the cause of all the symptoms ; and, in consequence, the same 
active treatment has not been adopted as in the other forms of 
apoplexy. This opinion will be best refuted by the investigations 
of Dr. Abercrombie, and I cannot do better than read for you the 
opinions of this eminent writer on the subject, as given in his cele- 
brated and admirable work, which, I have no hesitation in saying, 
constitutes one of the brightest ornaments of British medicine. 

" This distinction, which has been proposed between sanguineous 
and serous apoplexy, is not supported by observation. The former 
is said to be distinguished by flushing of the countenance and 
strong pulse, and by occurring to persons in the vigour of life ; the 
latter by paleness of the countenance and weakness of the pulse, 
and by affecting the aged and the infirm ; and much importance 
has been attached to this distinction, upon the ground that the 
practice which is proper and unnecessary in the one case, would 
be improper or injurious in the other. I submit that this distinc- 
tion is not founded upon observation, for, in point of fact, it will be 
found that many of the cases which terminate by serous effusion, 
exhibit in their early stages all the symptoms which have been 
assigned to the sanguineous apoplexy ; while many of the cases, 
which are accompanied by paleness of the countenance and feeble- 
ness of the pulse, will be found to be purely sanguineous ; and one 
modification of the disease in particular will be described, in which 
these symptoms are very strkingly exhibited, while the disease is 
found to be sanguineous apoplexy in its most hopeless form. 

apoplexy. Bricheteau relates twenty cases of this coincidence; among- others, of 
General Foy, the celebrated orator, and one of the liberal leaders in the French 
Chamber of Deputies. Bouillaud found in fifty-four cases of hypertrophy of the 
heart, that eleven exhibited also cerebral lesions, of which six were of apoplexy 
and five softening; of the brain. Dr. Hope, in a paper read before the College of 
Physicians, (1835,) on the connexion between apoplexy and palsy with organic 
diseases of the heart, relates, that out of thirty-nine cases of apoplexy, disease of 
the heart was found to be coexistent in twenty-eight.! 

M. Bricheteau draws the conclusion, that the periods of life at which fatal apo-; 
plexy is most prevalent, are those in which disease of the heart (either hypertro- 
phy of the muscular substance, or ossification of the valves and vessels), is of most 
frequent occurrence, namely, between forty and fifty, and between seventy and 
eighty years of age. 

The deductions for practical guidance, from these facts, are clear. They are, 
an avoidance of all severe bodily exercise, as well as of all exciting emotions of 
the mind. We ought also, as Bricheteau recommends, to direct the occasional 
application of leeches over the region of the heart, instead of to the temples or : 
any other part of the head — the internal use of digitalis, hydriodate of potassa, and! 
other diuretics— B.] 



APOPLEXY. 307 

III- ' , ■ . 4 - ^T-: r ;."'7 1 

1 " Portal has described a series of cases which afford the same 
I result; of three, which presented all the symptoms of serous 
| apoplexy, one was saved by repeated bleeding, and in the other two, 
which were fatal, there was found extensive extravasation of blood. 
I Case XCVL, lately described, forms a remarkable addition to these 
! observations. If any case could be confidentially considered as serous 
j apoplexy, this was such. Dropsical effusion had existed in the 
I body for months, and, in defiance of every remedy, it had been pro- 
| gressively gaining ground. There were symptoms indicating its 
! existence, both in the thorax and in the abdomen ; the patient then 
i became comatose, with pale countenance, and died : but though 
! dropsy was found in other cavities, none could be detected in the 
I brain. 

! "In other parts of the body serous effusion is very seldom a 
! primary disease : it arises as a result either of inflammatory action, 
! or of impeded circulation, and takes place slowly, not accumulating 
j at once in such quantity as to induce urgent symptoms. It is, 
j therefore, in the highest degree improbable, that it should occur in 
! the brain as a primary disease, and accumulate with such rapidity 

as to produce the symptoms of an apoplectic attack. 
I " The quantity of fluid effused, bears no proportion to the degree 
| of the apoplectic symptoms. We find it in small quantity, though 
the apoplectic symptoms had been strongly marked and long-con- 
I tinued ; we find it in large quantity when the symptoms have been 
slight; and, finally, we find most extensive effusion in the brain 
where there have been no apoplectic symptoms at all. The direct 
inference from these facts is, that, in the cases of apoplexy with 
effusion, the presence of the fluid cannot be considered as the cause 
of the apoplectic symptoms."* 

The same error has been committed with respect to hydrothorax, 
a disease almost never primary, but the result of either pleuritic , 
inflammation, obstruction of the heart or lungs, or some analogous 
cause. The cause of the symptoms is not the mere effusion of 
fluid, but some preexisting disease which has given rise to a serous 
effusion. In Dr. Abercrombie's work, you will find the remarkable 
fact stated, that there may be a copious effusion of serum in the 
head, without producing apoplectic symptoms. The following 
case, mentioned by Dr. Abercrombie, furnishes a remarkable illus- 
: tration : — A patient, who had laboured under hypochondriasis for 
upwards of thirty years, began to decline rapidly in health. He 
was extremely feeble, his bowels costive, his sleep disturbed, and 
his appetite gone. This state continued for some time, and he 
| began to sink, but he never complained of headache, giddiness, 
|i convulsions, or paralysis, and his mental powers remained unim- 
, i paired until a very short time before his death. Yet, on opening 

I j * [This view had been taken so long ago as 1792, by Dr. Physick, in his inau- 

f j gural thesis, De Jlpoplexia, printed at Edinburgh. See Dr. J. R. W. Dunbar's 

\ | Inaugural Essay on the Structure, Functions, and Diseases of the Nervous Sys~ 

I tern. Philadelphia, 1828. — B.] 



I 
1 



308 



STOKES'S THEORY AND PRACTICE. 



the head, there was an exceedingly copious effusion of serum found 
under the arachnoid ; and in some places this was so great as to 
give the arachnoid the appearance of small bladders filled with 
water. The ventricles were distended with fluid. Dr. Abercrom- 
bie gives another case, where the quantity amounted to eight ounces, 
and notices a case, mentioned by Dr. Marshall, of a maniac who 
died of mortification of the feet ; a few hours before death he became 
perfectly rational, yet effusion was found both on the surface of the 
brain and in the ventricles, amounting to more than a pound. 

All these facts go to prove, that what has been termed serous 
apoplexy is only an apoplectic attack depending on congestion of 
the brain ; that in some cases we may have this congestion accom- 
panied by serous effusion, in others not; that the effusion is second- 
ary, and by no means of constant occurrence ; and that altering 
our practice, and pursuing a less active plan of treatment, in such 
cases, would be improper. The same treatment should be adopted 
in the serous, as in the congestive form of the disease, for where the 
nature of the affection is the same, the same curative means should 
be employed. Why it is that effusion takes place in one case, and 
not in another, we cannot tell ; such changes are connected with 
laws of organization, of which we are at present ignorant. We 
know as little why this should occur as why inflammation of the 
liver in one case is followed by enlargement, in another by the 
secretion of pus, in a third by cancer, or in a fourth by hydatids. 

We now come to the consideration of apoplexy with extravasa- 
tion of blood. This is the form of the disease to which the term 
apoplexy has been restricted by one of the last writers on the sub- 
ject, M. Rochoux. In this affection, the extravasation of blood, 
which constitutes the principal pathological feature of the disease, 
is found to exhibit a remarkable variety as to its seat and extent. 
In some cases, the blood is effused on the surface of the brain ; in 
others, into its substance ; and in a few cases into the ventricles. 
De Haen gives some cases of apoplexy produced by rupture of the 
choroid plexus ; but, in the great majority of cases, where blood is 
found in the ventricles, the extravasation has taken place in one 
hemisphere, and, tearing through the substance of the brain, has 
made its way into their cavities. Of the three varieties of apoplectic 
effusions, the ventricular is the rarest ; the next to this is the 
meningeal, or that in which blood is poured out on the surface of 
the brain, and the most common is where it is effused into the sub- 
stance. It has been also found that certain parts of the brain are 
much more liable to sanguineous effusions than others ; of the 
reason of this, as of many other phenomena connected with the cir- 
culation of the brain, we are still in ignorance. The following 
table, which you should bear in mind, exhibits a remarkable prepon- 
derance in the liability to sanguineous effusions of certain parts of 
the brain. It has been taken from the "Precis d'Anatomie Patho- 
logique" of Andral. The following is a summary of the results of 
386 cases of apoplexy. 



APOPLEXY. 



309 



In 202 cases, the effusion took place into the substance of the 
hemisphere of the brain, in that part which is on a level with the 
corpora striata and optic thalami. The portion of the brain next 
most liable to effusions, are the corpora striata ; and here we have 
61 cases. Next to this are the optic thalami, in which we have 35 
! cases. In that proportion of the hemispheres above the centrum 
| ovale, 27 cases. Lateral lobes of the cerebellum, a proportion of 
! 16 cases. In those portions of the brain anterior to the corpus 
i striatum, 10 cases. In the mesocephalon, 9. Spinal coraVS. Pos- 
! terior lobes of the brain, 7. Middle lobe of the cerebellum, 5. Pe- 
I dunclesof the brain, 3. Olivary bodies, peduncles of the cerebellum, 
! and pituitary gland, 1 in each, making 3 — total 386. Out of these, we 
find 325 cases occurring in the hemispheres of the brain, corpus 
! striatum, and optic thalamus. 

In the number and size of these effusions we find the greatest 
varieties. In some cases, an enormous effusion takes place, and 
many ounces are extravasated into the substance of the brain ; in 
! others, the quantity is trifling, being sometimes as small as a pea, 
or even less. It has been observed that in cases where numerous 
extravasations were discovered, they were generally found to be in 
different states, as if they had occurred at intervals, and not simul- 
taneously. This leads us to the knowledge of one of the most 
important facts in pathology, that in many cases of apoplexy, after 
a clot has been formed, nature commences, at an early period, a 
I process of cure. The change, which takes place in cases where a 
patient recovers, seems to be the following : — It becomes, at first, 
somewhat gelatinous; it is next observed to be more consistent, and 
it loses its red colour, and takes on a whitish or yellow appearance. 
The clot is gradually removed ; and along with the absorption of 
the clot there is a process of isolation going on. A fine membranous 
cyst, furnished with vessels, is formed round the clot. In some 
cases, the clot is replaced by a quantity of serous or gelatinous 
fluid; but in the majority of instances this does not occur, and the 
cyst has been found empty. This is a fact which has been esta- 
blished by numerous observations. 

There is the greatest possible difference as to the period at which 
the absorption of the clot is completed ; but we may safely assert, 
from the number of cases in which, after paralysis, a recovery takes 
place, that this process is of very common occurrence. In several 
eases, where apoplexy, followed by paralysis, has happened several 
\ times during the lifetime of the patient, a number of those cysts, 
> corresponding with the number of attacks, and presenting various 
j appearances according to the date of their formation, have been 
, found. It appears, then, that the cure of apoplexy depends solely 
i on the absorption of the clot; and that, as long as this remains 
| unabsorbed, the patient is in danger. In some cases, absorption 
does not take place at all, the clot becomes organized ; and in this 
! way it is supposed that some of the tumours found in the brain are 
! formed. There are several circumstances which favour the absorp- 

27* 



310 



STOKES'S THEORY AND PRACTICE. 



tion of the clot, but nothing so powerfully as a healthy condition of 
the whole cerebral circulation. This leads us to the consideration 
of the importance of paying attention to the head, long after an 
attack of apoplexy. It inculcates the necessity of avoiding every 
thing calculated to add to the existing congestion; and shows that, 
in the paralytic or after-stage of an apoplectic attack, we should not 
neglect to deplete the head from time to time. The great point is 
to keep the head perfectly free from irritation ; for it has been found, 
that, where a cure appeared to be going on, any new irritation 
applied to the brain has had the effect of arresting the absorption of 
the clot, and marring the process of cure.* 

I regret I cannot dwell longer on this subject, as I wish to con- 
clude the pathology of apoplexy to-day. There are, however, two 
more observations to be made before I close the subject. The 
source of an apoplectic effusion is very hard to be discovered ; it 
appears generally to come from a number of minute vessels, for we 
are seldom or never able to trace it to the rupture of a vessel of any 
size. The age at which persons are most subject to apoplexy, 
appears to be from fifty to seventy. You should, however, be 
aware that apoplexy with sanguineous effusion is by no means 
uncommon, even in persons of a tender age. Billard details an 
instance of this in a child, soon after birth. There are also several 
cases mentioned as occurring in children during the first three or 
four years. Andral gives the case of a boy of nine years of age, 
who died of apoplexy, with a vast effusion of blood. One of the 
most remarkable cases of this kind I ever witnessed, occurred in a 
child who had been just weaned. This child had been labouring 
for some time under symptoms resembling incipient hydrocephalus, 
and then suddenly got an attack of convulsions, followed by coma 
and paralysis of one side. From a careful study of the symptoms, 
I ventured to make the diagnosis of apoplectic effusion, and on 
examining the brain, after death, there were nearly three ounces of 
blood found effused in the base of the brain. 



LECTURE XXIX. 

Apoplectic effusions — Curative process adopted by nature — Periods of life most subject 
to apoplexy — Connection of temperaments [and sex] with disposition to apoplexy — 
Researches of Rochoux — Principles of diagnosis — Varieties of apoplexy — Connec- 
tion of. symptoms with pathological appearances — Rostan's division of — Different 
symptoms of — Double effusions — Rupture into ventricles — Hemiplegia — Value of the 
suddenness of paralysis as a diagnostic examined — Symptoms of apoplectic effusions. 

At my last lecture, I spoke of the nature of apoplectic effusions; 
I stated that they exhibited a considerable variety as to their situa- 

* [I have known this effect to be caused by the secondary irritation from a dis- 
tended stomach. The patient, a female in advanced life, was recovering from the 
first attack, for which active depletion had been used, and rigid abstinence 
enjoined, when she yielded either to evil appetite or evil suggestion of another, 
and ate heartily of strong, gross food. It was her last meal. — B.] 



APOPLEXY. 311 

! tion, extent, number, and condition in different eases; that it was 
j frequently a matter of great difficulty to ascertain their source, and 
that they might occur at any age, but chiefly from that of fifty to 
seventy. I gave a brief sketch of the process adopted by nature in 
j effecting a cure, and showed that in many cases, where the effused 
' blood is absorbed, there is scarcely any trace of the disease, except 
! a slight cicatrix ; but that in some instances, where the sanguineous 
effusion has been removed, its place becomes occupied by a quantity 
| of serous fluid, and this, with the cyst which contains it, seems to 
' explain what the old anatomists termed false ventricles. You will 
I find, by looking over some of the earlier writers on anatomy, that 
they have described the brain as containing more than the ordinary 
I number of ventricles, and the mistake seems to have arisen from 
' their taking for ventricles those serous cysts or cavities which 
! remained after the absorption of an apoplectic effusion. Of course 
other causes, such as congenital formation, may give rise to the 
appearance. You will see in the museum of the College of Sur- 
geons a fine specimen of abnormal cavities filled with serum in 
different parts of the brain, 

In speaking of the period of life at which apoplectic disease is 
most frequent, I stated, that though it might occur at any time of 
life, still there was a particular period at which there is a greater 
liability than any other. Rochoux has shown that the tendency to 
apoplexy is greatest towards sixty, and diminishes towards seventy 
1 years of age. The number of cases which occur between sixty 
and seventy are very great, w r hen compared with those between 
seventy and eighty ; and after eighty he considers the liability to 
be still farther diminished. It seems strange, that persons after 
seventy should not be so liable to attacks of apoplexy as before that 
period, but such is the fact. It has been thought that this may be 
explained by the ansemic state of the brain in old persons ; it is 
said, that at such an advanced age general emaciation takes place, 
and the quantity of blood is greatly diminished. This explanation, 
however, is doubtful, because it is at present well ascertained, that 
persons of ordinary development, who are nether fat nor thin, and 
also persons of spare and delicate habit, are as much, and even 
more, liable to apoplexy than the fat and plethoric. It has been 
ascertained by careful investigations, that a high degree of plethora 
does not necessarily predispose to the disease, and that it is oftener 
j met with in persons not of a plethoric habit than in those who are. 
j These considerations throw some doubt on the opinion that an 
' exemption from apoplectic attacks is connected with an anaemic 
! condition of the system. It generally happens, however, that at 
I this advanced period of life, from the general debility of the system 
j and the incapacity for active exertion, a man ceases to employ his 
I thoughts about business, and there is little exercise for the intel- 
| lectual functions. We now have finished the task; the brain 
| reposes from the turmoil of active and incessant thought; there is 



! 



312 



STOKES'S THEORY AND PRACTICE. 



a comparative absence of mental exertion, and this may in some , 
degree account for the rarity of apoplexy after the age of seventy.* 

With respect to the different temperaments as bearing on this > 
point, Rochoux shows that in Paris, at least, there was a nearly 
equal frequency of the disease in individuals of the sanguine, san- ; 
guineo-bilious, and sanguineo-iymphatic constitutions. The bilious 
temperaments, however, are much less liable. Such is the result | 
of the observations in Paris ; but it must be recollected, as Rochoux 
observes, that in that city the bilious temperament is the rarest. | 
With respect to the sanguine or plethoric, it has been found that ( 
this temperament does not predispose to apoplexy so much as has 
been generally supposed. The disease has been observed to be most t 
common in persons of ordinary development, next to those in per- i 
sons of thin, spare habit, and last of all in the 'plethoric and fat. 
Rochoux's researches lead him to conclude that the number of per- 
sons of ordinary development, attacked by apoplexy, is three times | 
that of the plethoric, and that that of the spare habits is little more ) 
than twice as great as that of the fat and plethoric. If these re- i 
searches are correct, they afford great consolation to stout gentle- j 
men. j 
The conclusion, which has been come to, with respect to tern- ' 
peraments as bearing on the liability to apoplexy, appears to be 
true, namely, that there is no sign appreciable by the senses which 
will unequivocally point out a predisposition to apoplexy. This is 
of great importance in a practical point of view. You may expect 
the disease in the fair or dark haired, the thin or fat, alike. The : 
frequent occurrence of this disease in persons who were never sus- ; 
pected to have any predisposition to it is another proof in favour of I 
this opinion. With respect to the mere medical diagnosis of apo- 
plectic effusion, it would be well if, in making it, you would always 
bear in mind the anatomical characters of the disease. Extrava- J 
sation of blood into the substance of the brain generally takes place ] 
by a tearing or separating of the cerebral tissue. A quantity of ) 
blood is rapidly effused, the substance of the brain torn, and a cavity : 
formed. There can be no doubt that the tissue of the brain is torn, ■, 
for we can see the loose shreds hanging on each side of the cavity, 
and mixed up with the clot. Now what are the principles which 



should guide us in making our diagnosis? They are exactly the . 
same as those in other diseases connected with a sudden solution 

* [Of 69 cases recorded by Richoux, the distribution, in respect to age, was as r 
follows : — 

From 20 to 30 years, 2 cases. 

" 30 to 40 ' " 10 " F 

" 40 to 50 " 7 " 

" 50 to 60 " 13 " 

" 60 to 70 " , . . 24 " 

" 70 to 80 " . . . . . . . . 12 " 

" 80 to 90 " . . . . . . . . 1 " 



69— B.] 



APOPLEXY. 



313 



j of continuity in the substance of internal organs. We have, with 
j or without any preceding symptoms of a different kind, the sudden 
: supervention of new and remarkable phenomena. The pheno- 
j mena which are the result of disease proceeding in its ordinary 
' course are gradual and progressive ; but occurrences of this kind 
i are almost always characterized by sudden and well-defined symp- 
| toms. Thus, we make the diagnosis of the rupture of an aneurism 
of the aorta from the sudden vomiting or expectoration of blood, 
i followed by the death of the patient. Here, you perceive, the 
1 diagnosis is founded on the' sudden supervention of new symptoms, 
i In the same way we make the diagnosis of pneumothorax with a 
: fistulous opening communicating with the bronchial tubes, and 
i calculate, from the sudden occurrence of pain in the side and the 
; other signs of pneumothorax, that there has been a solution of 
! continuity in the pleura. Again ; if a person labouring under 
hepatic abscess is seized with a fit of coughing, and suddenly 
expectorates a quantity of pus, and that this is found to be accom- 
panied by a subsidence of the tumour in the region of the liver, we 
'■■ make the diagnosis of perforation of the diaphragm and pleura, and 
the escape of the contents of the abscess into the substance of the 
lung. Or he may, under the same circumstances, be seized with 
sudden and rapid peritonitis, and here we make the diagnosis of an 
effusion into the peritoneum. It is on precisely the same principles 
that Louis has established the diagnosis of perforation of the small 
1 intestines in cases of gastro-enteritis. The patient is lying in bed, 
perhaps apparently improving ; he is not exposed to any exciting 
cause, and every care may have been taken of him. On a sudden 
he exhibits symptoms of intense peritonitis, and rapidly dies. Any 
one conversant with such cases can easily make a correct diagnosis. 
On the same principles we found the diagnosis of apoplectic effu- 
sion. Almost all the instances of disease which I have given occur 
with a sudden violent invasion ; and the same thing may be said 
I of apoplexy with extravasation. It is true, that there are some 
i cases which do not exhibit this character, but the general rule is 
| suddenness of attack.* 

We may divide apoplectic attacks accompanied by extravasation 
i into three great classes ; and, if you look to the great majority of 
| cases of this disease, you will find that, although they appear to pass 
! by insensible degrees into one another, still, when taken and examined 
! singly, there will be found a difference between them. This clas- 
| sification is that of Rostan, and I have known his principles veri- 
' fied in many instances. In the first class of cases, which are the 
I worst and generally prove fatal, the extravasation is enormous. A 
j£ ' ' v 

I * [As regards the predisposition to apoplexy dependent on sex, we find that 
j more men than women are attacked with the disease. P. Frank shows that, out 
I of 1241 cases of fatal apoplexy in the hospital at Vienna, during the period be- 
j tween 1787 and 1804, there were 637 men and 604 women. M. Fabrel, in his 
j statistics of apoplexy, indicates a greater difference. Thus, out of 2297 cases of 
1 the disease, there were 1670 men and 627 women. — B.] 



I 



314 STOKES'S THEORY AND PRACTICE. 

person, apparently in perfect health, will fall down in a fit of apo- 
plexy, remain for a short time insensible and paralytic, and then \ 
die. In such a case as this, the ordinary pathological character is ) 
an enormous effusion of blood, or excessive congestion. In a case I 
of the second class, we have an apoplectic seizure with coma, ; 
which disappears after some time, and the patient recovers his k 
intelligence, but with paralysis of one side. The pathological j 
character of this form is, that the effusion is more limited and - 
exists only on one side of the brain. Neither is the congestion so \ 
severe, and the patient recovers from the coma. In the third form, f 
we have an attack of apoplexy of a milder description ; there is t 
scarcely any coma or loss of intelligence, and the paralysis is slight, ! 
generally affecting the muscles of one side of the face or of one of i 
the extremities. Let us repeat these varieties. In the first, which 5 
constitutes the apoplexie foudroyante of the French, there is an : 
enormous extravasation of blood in both sides of the brain ; or, if I 
it be only on one side, the amount of the effusion is frequently such : 
as to burst through the walls of the ventricles and get into their I 
cavities, and in this way we may have an effusion of one side get- 
ting into the other hemisphere, or exercising such pressure on it as 
niay give rise to general symptoms. Such a case as this is, I 
believe, generally fatal ; its progress, too, is very rapid, several 
persons under such circumstances having died in the space of an 
hour or less. In the second form, there is coma and loss of intelli- \ 
gence, and the patient recovers with paralysis of one side. Here 
the extravasation is never so great as in the foregoing case ; the 
effused blood is confined to one side, and does not get into the ven- 
tricles. In the third form, the effusion is very much circumscribed, ji 
the signs of general congestion or extravasation are slight, the 
quantity of blood poured out is not, perhaps, larger than a nut, it is ji 
followed by partial paralysis, and there is little or no coma or loss 
of intelligence. 

Let us take a brief review of the symptoms which attend each i 
of these forms. In a case of the first description, we find a person, \ 
hitherto in the enjoyment of health, suddenly attacked with symp- ! 
toms of intense apoplexy. You will recollect that in my last lec- f 
ture, I told you that apoplexy consisted in various lesions of the 
phenomena of the life of relation. In the most violent form of 
apoplexy, many authors are of opinion that there is a total paralysis " 
in the functions of animal life. The patient falls down and remains 
in a state of complete insensibility, the eye no longer obeys the 1 
stimulus of light, no sound makes any impression on the ear, of 
odour on the sense of smelling, the sense of taste is destroyed, 
the skin may now be seared w T ith a red hot iron without the 
slightest indication of suffering; in fact, sensation, one of the great 
phenomena of animal life, appears to be annihilated. If weexamine 
further, we find that there is a total suspension of the intellectual 
functions, and that the patient is unconscious of anything passing 
around him. If we go to the muscular system, we find that all 



APOPLEXY. 



315 



that part of it which subserves to the purposes of animal life is 
completely paralysed. The neck, trunk and extremities have lost 
their power ; and, if you raise the head, trunk or one of the limbs, 
they fall down like dead masses, as soon as the support is with- 
drawn. In some cases there is a certain degree of rigidity in the 
muscular system, in others not. We may observe also, that from 
the paralysis of the buccinators, the cheeks are alternately puffed 
out and sucked in during respiration. As far as my experience 
goes, I believe that this symptom is fatal. Here, then, we see that 
the great phenomena of the life of relation are suspended. The 
functions of organic life, however, still continue to be performed, 
the heart beats, respiration goes on, and the power of secretion 
remains ; but, after some time, the functions of organic life are 
also, suspended, and the patient dies. In some of these cases, we 
observe evident signs of determination of blood to the head, the 
face is swollen, and the lips livid; there is considerable turgescence 
of the vessels of the neck, with heat of the head, the skin hot, and 
the pulse full and strong. In other cases, however, we have a 
feeble pulse and a cold collapsed state of the surface. 

Let us now turn for a moment to the pathology of this form of 
the disease. I have already mentioned, that the extravasation 
I sometimes, occupies both hemispheres of the brain, or that it occurs 
j on one side, and, by tearing through the substance of the brain, 

• gets into the ventricles, and produces symptoms referable to a lesion 
of both sides. With respect to the simultaneous double effusion, 
the following is a short notice of some cases taken from the 
" Clinique Medicale" of M. Andral. A man, about thirty-seven 
years of age, fell down near La Charite in a fit of apoplexy. He 
was immediately brought into the hospital, had prompt and careful 
attention paid to him, but without any effect ; he lay in a state of 
profound coma, with complete suspension of the phenomena of 
animal life, and died in an hour and a half. On examination there 
was a double effusion of blood found in the brain, but it had not 
got into the ventricles. In another case, marked by simple intensity, 
there was an enormous effusion discovered in the substance of one 
hemisphere, which burst into the ventricle, tore through the septum 

i lucidum, and passed into the ventricle of the opposite side. In the 
! next case, no distinct trace of optic thalamus or corpus striatum 
j could be seen, their substance being completely broken up and de- 
' stroyed by the effusion. I have told you that, after a rupture of the 
| substance of the brain and the escape of the effused blood into the 
' ventricles, persons have not recovered, but it is a fact, and a con- 
I solatory one indeed, that a person may recover from a simultaneous 
, double effusion. A- case in proof of this is given by Andral. A 
: female who had been for some time a patient at La Charite, died of 
I cancer of the stomach. The history of her case was, that nine 
j years before she had an attack of apoplexy, she had fallen down in 

* a state of insensibility, and remained comatose for a considerable 
! time, that this was followed by paralysis of both sides of the body. 



316 STOKES'S THEORY AND PRACTICE. 

which continued for two years, after which she gradually recovered 
the use of her limbs. In this case, two serous cysts, such as are - 
met with in cases where patients have recovered from apoplectic 
attacks were found, one in each hemisphere of the brain. In another 
case, the subject of which died of visceral disease, the patient had 
twenty-two years before an attack of apoplexy with double para- 
lysis, and recovered with the loss of the use of one side ; here there 
•were two cysts also found. It appears, then, that though extrava- 
sation, w T ith rupture of the walls of the ventricles, and escape of 
blood into their cavities, always proves fatal, a recovery may take 
place after a simultaneous double effusion. 

Let us now inquire briefly, whether an apoplectic attack, followed 
by paralysis of both sides of the body, gives sufficient grounds to 
enable us to make the diagnosis of either of these accidents. Does 
it follow, if a person has an attack of apoplexy, succeeded by para- 
lysis of both sides, that the effused blood has burst into the ventri- 
cles, or that a simultaneous double effusion has occurred \ Andral 
inclines to this opinion as far as I can collect. Dr. Abercrombie 
appears to differ from him, and gives eases in illustration of his 
opinions. The following is one : — A private of the 10th Hussars 
has been complaining for some time of a pain in the head, for which ( 
he was blistered, and the pain soon went off. On the 22d of July, 
1819, he was seized with giddiness and fell down ; on being raised, 
he vomited, and complained of violent headache and faintness, but 
was quite sensible. He was very pale, and his pulse slow and lan- 1 
guid. He was brought into the hospital, where he asked for some 1 
cold water, made a few inspirations, and expired. From the 
moment of his last seizure he had been paralytic of both extremities; 
Here we have an attack resembling the first form of apoplexy, so : 
far as complete loss of power in the upper and lower extremities is 
concerned, but observe, the patient was not comatose, and retained 
his faculties to the last. On examination there w<as nothing found 
amiss with the brain, but, on removing the cerebellum, a coagulum 
to the amount of about two ounces was found under and surrounding 
the foramen magnum. Here the paralysis appears to have been 
produced by the pressure of the effused blood on the upper part of ; 
the spinal cord. This case is an interesting one. It appears that ■ 
the injury done to the functions of the life of relation was partial, - 
there was a lesion of t'he muscular function, but there was no coma, 
and the intellectual faculties were unimpaired. As far then as a single 
case goes/we may come to the conclusion, that we are not to make 
the diagnosis of the first form of apoplexy, unless, in addition to the 
double paralysis, there are coma and loss of intelligence and sen- 
sation. The great points of diagnosis are coma, suspension of the 
phenomena of the mind, and paralysis of both sides of the body, 
both of motion and sensation. We now come to consider the 
symptoms of the second or milder form of the disease. A person 
falls down in a state of insensibility, but, when you come to examine 
him, you find that the coma is not so profound, nor is the paralysis 



I 



APOPLEXY. 



317 



and loss of sensation so complete. The eyes are to a certain degree 
susceptible of the impressions of light, signs of uneasiness are ex- 
hibited when strong pungent odours are applied to the nostrils, and 
j indications of suffering are given if you pinch or burn the skin, 
i All these circumstances prove, that the paralysis of sensation is by 
j no means so complete in this as in the former case. You observe 
| here, too, that instead of the cheeks being pulled out in the manner 
| before described, there is only a partial paralysis of the muscles of 
j the face, and the mouth is drawn towards the sound side. The 
! patient, too, instead of dying in a comatose state, gradually regains 
, his intelligence, and is only paralysed on one side, or one extremity, 
i All these circumstances point out that the injury done to the brain 
, is not so extensive, and the occurrence of paralysis on one side 
| shows that the effusion is limited to a single hemisphere of the brain. 
I All this, too, is borne out by pathological anatomy, which shows 
! us, in the first place, that the extent of the effusion is much less, 
j that it exists only on one side of the brain, and never bursts into the 
i ventricles. The general congestion of the head also is much less 
! than in the former case. In the third form, the congestion and 
other symptoms are sometimes very slight. A person in health 
may feel a stunning sensation in the head, followed by some thick- 
ness of speech and drawing of the mouth to one side, or slight para- 
lysis of one arm or hand, but he has no coma or loss of intel- 
ligence, and the paralysis quickly disappears. Everything con- 
| nected with the attack shows that it is very slight, the effusion is 
extremely limited, and this is confirmed by pathological anatomy. 

I have now given you a brief sketch of the three varieties of 
apoplexy ; between these you will meet with many intermediate 
cases. 

Let us inquire how far does the circumstance of paralysis point 
out the occurrence of an extravasation of blood into the substance, 
or on the surface of the brain ; that is, how far we can say that this 
patient has effusion, because he has become suddenly paralytic. It 
would appear, that the mere suddenness of the attack will not alone 
lead to the formation of a certain and accurate diagnosis. You 
will find in various authors many instances of affections of the head, 
j not of an apoplectic character, in which there was sudden paralysis. 
Thus, for instance, there are many cases of tumours and encysted 
abscesses on record in which there was sudden paralysis, and 
where, if you should pronounce the disease to be apoplexy, you 
would be certainly wrong. We had lately, at the Meath Hospital, 
a remarkable instance of this. A patient, who had been for a con- 
j siderable time labouring under aneurism of the innominata, in the 
; course of the night became suddenly hemiplegic. On examining 
! the brain, post-mortem, there was a circumscribed abscess found 
j in one of the hemispheres, but no sanguineous effusion. If you 
I look to the works of Abercrombie, Rostan, Lallemand, &c, you 
| will find many cases detailed in which sudden paralysis occurred 
| from other causes than apoplexy. 

28 



| 



31S 



STOKES'S THEORY AND PRACTICE. 



But are there no circumstances, which, combined with the sud- 
denness of the attack, would lead us to form the diagnosis of apo- 
plexy? Now it would appear that, as a diagnostic of apoplectic 
effusion, suddenness of paralysis is only to be relied on where 
there have been no premonitory symptoms of a local disease of the 
brain. In the great majority of cases of cerebral abscess, you will 
find that pains and cramps in some of the limbs, and pain of the 
head in the situation of the abscess, have preceded for some time 
the paralytic attack. But if a person in health, without any of 
these cramps or pains, gets a sudden attack of apoplexy, and 
becomes hemiplegic, you may make the diagnosis of apoplectic 
effusion with tolerable certainty. The fact of the paralysis occur- 
ring with an apoplectic seizure, renders it highly probable that the 
case is really one of the hemorrhagic diseases of the brain. On 
the other hand, it is true that we may have apoplectic effusions 
ushered in by symptoms of irritation of the brain ; as in the case of b 
an apoplectic effusion occurring in the centre of a softening of the 
brain. The absence, therefore, of these premonitory symptoms 
appears to be necessary towards forming the diagnosis of simple 
apoplectic effusion. 



LECTURE XXX. 



; 



Apoplexy from ramollissement (softening) of the brain — Supervention of apoplexy on 
encephalitis — Inflammation round the clot — Variety of paralysis consequent on 
apoplexy — Paralysis croissee — Different forms of paralysis — Origin — Phenomena of 
face and tongue — Paralysis of the tongue — Treatment of apoplexy — Blood-letting 
— Purgatives — Lotions, beneficial effects of — Emetics, dangerous effects of — Use of 
revulsives and stimulants — Treatment of paralysis — Efficacy of strychnine — Its 
modus operandi — Brucine, its proposed employment. 



I left off at my last lecture in considering how far the mere 
circumstance of suddenness of attack with paralysis could be 
considered as leading to the diagnosis of apoplectic effusion, and 
endeavoured to show that mere suddenness of attack with para- 
lysis was insufficient to form a diagnosis, except where they 
occurred in a person who had no previous symptoms of irritation of 
the brain ; — these symptoms being pain of the head, and pains, 
spasms, and rigidity of the limbs. I wish to impress upon you, 
that you may have an attack of apoplexy with effusion ushered in 
by all these symptoms, particularly in cases where the apoplectic 
effusion is consequent on a localised inflammation of the brain. A 
portion of the brain, for instance, becomes inflamed and disorgan- 
ized ; local ramollissement (softening) takes place; and it may 
happen that this, acting as a point of attraction to the fluids, may 
lead to the occurrence of an apoplectic effusion in the originally 
affected portion; and in this way you will have apoplexy preceded 
by all the symptoms which characterize a partial encephalitis. 
You will perceive, then, that the absence of these premonitory 



APOPLEXY. 



319 



symptoms is necessary towards forming a certain diagnosis of 
apoplexy with effusion. If these symptoms have preceded the 
attack, it is probably either circumscribed abscess of the brain, or 
it is local inflammation followed by effusion. Between these two 
forms of disease we have no means of distinguishing. 

Before I speak of paralysis I wish to make some remarks on a 
condition of the brain which supervenes in certain cases of apo- 
plexy. In cases where absorption of the clot takes place, we can- 
not suppose that any inflammatory condition of the brain exists; 
on the contrary, we have every reason to believe that a non- 
inflammatory condition of the brain is highly favourable to this 
process, for whenever anything of an opposite character happens, 
w r e find that it prevents absorption. But sometimes cases occur, 
in which, at an earlier or later period, inflammation is set up round 
the clot. Now, what happens in many of these cases If Here let 
me repeat, that there are many exceptions to the rules given for 
I forming the diagnosis of disease of the brain ; the variety in the 
[ symptoms of cerebral affections being so great, that it is sometimes 
; difficult to deduce from them rules of general application. In most 
cases we have apoplexy followed by paralysis with resolution ; 
but, in cases where inflammation takes place round the clot, it has 
been observed that the paralysed limb which had been previously 
in a state of resolution becomes contracted, and then we have 
paralysis with contraction. This contraction generally comes on 
! in a gradual manner, but, when the case is severe, it is frequently 
ushered in by violent spasmodic action of the affected limbs. We 
have, then, the following order of phenomena ; first, paralysis with 
resolution, and then paralysis with contraction. In circumscribed 
inflammation of the brain, the phenomena are the reverse of these ; 
we have, first, rigidity and contraction of the limbs, and then 
symptoms of apoplexy followed by paralysis with resolution. 

With respect to the paralysis which is consequent on an attack 
of apoplexy, there is the greatest possible variety. In some cases 
there seems to be paralysis of all, or almost all, of the muscles of 
animal life; in others, it affects only the muscles of one side of the 
body. A rare and extraordinary form of paralysis has been 
described by the French writers, who have given it the name of 
| paralysis croissee. In this form of the disease there is an affection 
1 of both sides, but not of the symmetrical members; we find the left 
arm and the right leg paralysed, and vice versa. This is an unu- 
sual form, in fact the rarest to be met with in practice. We may 
I also have great varieties in the amount of the paralysis ; in some 
j cases both sides being affected, in others only one, while in others 
I there is only a single extremity or one side of the face paralysed. 
| We may also have complete paralysis of one side without any 
| affection of the face. I remember a remarkable case of this kind, 
j of which 1 shall give you an abstract. A gentleman, of stout 
! muscular habit and a strong full pulse, had been suffering for a 
! long time under an obstinate gouty affection. From a reputation of 



320 



STOKES'S THEORY AND PRACTICE. 



the gouty attacks he got a chronic swelled state of the lower 
extremities, which continued for some time, he being in other 
respects in the enjoyment of excellent health. The swelling, how- 
ever, preventing him from taking his usual exercise, he applied for 
advice. Laced stockings were advised, the effect of which was, 
that the oedema subsided, and the motion of the lower extremities 
was restored. It is curious, that, between the period of the re- 
moval of the oedema and the paralytic attack which I am about to 
describe, this gentleman enjoyed excellent health. At the end of 
that time, on attempting to go over a step that led into the yard, 
he found he could not accomplish his purpose, and struck his foot 
against the stone. He immediately became alarmed and sat down, 
and soon after found that he had lost the power of using his arm. 
I saw him in a short time after the accident, and found that there 
was complete paralysis of the arm and leg, but no distortion of the 
face or tongue, or the slightest lesion of intelligence. He continued 
in this state for some time, and then recovered, but it was neces- 
sary to take a large quantity of blood from him. In the first 
bleeding, as the pulse was full and bounding, I took sixty ounces 
of blood from the arm, and I think it was owing to the activity of 
the measures adopted that he recovered so speedily. I mention the 
case merely to show that we may have paralysis of the leg and 
arm, without any affection of the face, or loss of intelligence. In 
some cases we find the paralysis affecting the tongue, face, and 
muscles of the eyelids; in some we have paralysis of the sphincter 
ani, or of the muscles of deglutition, or of the bladder, but these are 
rare, and the most ordinary form is paralysis of the muscles of one 
side, and distortion of the face. There is another circumstance, 
w r hich seems to be so exceedingly frequent as to form a law, per- 
haps the most general of any in medicine, that paralysis occurs on 
the side of the body which is opposite to that on which the effusion 
occurs. If you have an effusion into the right hemisphere, you 
will have paralysis of the left side of the body, and, if the effusion : 
be on the left side, the paralysis will be on the right. To this rule, I 
however, it has been stated that there have been a few exceptions ; ! 
how they have occurred it is totally impossible to explain ; it is 
sufficient for us to know that such exceptions have been witnessed. 
Cases of this description have been very rarely seen since patholo- 
gical anatomy has been studied with more diligence ; it is however 
true, that a few have been detailed by men of great professional 
eminence. We want facts to throw light on this point, and, until 
this is accomplished, we must remain in ignorance of the cause of 
the anomaly. In the vast majority of instances, the paralysis is on 
the opposite side to that on which the effusion takes place, and this 
appears to be explained by the decussation of the fibres of the brain 
at the upper part of the spinal marrow, the fibres of the left side 
passing to the right and vice versa. It is an interesting fact 
connected with this subject, that the muscles of the face follow the 



APOPLEXY. 



321 



same law as the muscles of the extremities, and yet it is a fact, as 
I you are well aware, that the nerves which supply the muscles of 
the face come off before the decussation of the fibres of the brain 
j takes place. The fifth nerve, which supplies the face with muscu- 
j lar branches, is given off at a considerable distance from the decus- 
sation of these fibres, and yet we perceive that the muscles to which 
! it is distributed obey the same law as those which derive their 
' nerves from the spinal cord. Now, if this decussation was the only 
cause of the paralytic symptoms being observed on the side oppo- 
! site to that in which the effusion occurs, the muscles of the face 
should be an exception to this law ; but we find that they cor- 
respond with other parts of the muscular system in this respect. 
Thus, if a man gets an attack of apoplexy, followed by paralysis of 
! the left arm, we find the left, side of the face affected, and vice versa. 
We must conclude from this, that the mere decussation of the fibres 
is not the sole cause of this peculiarity, and must look for an expla- 
nation elsewhere, by referring it to the intimate communication 
' which exists between both sides of the brain by means of its com- 
' missures. Many persons are not familiar with the phenomena of 
the face and tongue in paralysis ; they are, however, simple and 
j easily explained. Let this diagram represent the head— here we 
have the right hemisphere of the brain, here the left. Now, suppose 
you have an apoplectic effusion in the right hemisphere, the conse- 
quence is that you have paralysis of the left side of the body, 
according to the law already mentioned. What will then happen 
; with respect to the face is, that the muscles of the left side being 
paralysed, and their antagonism destroyed, the mouth is drawn by 
the sound muscles of the opposite side from the paralysed side, and 
this is invariably the case. Recollect, then, that the mouth is 
always drawn from the paralysed side, and towards that side where 
the disease exists in the brain. But when you desire the patient to 
put out his tongue, do you find that the tongue follows the direction 
of the mouth'? No; it goes towards the opposite side. This ap- 
; pears somewhat paradoxical at first, but is easily explained. The 
protrusion of the tongue is effected by the action of the genio-hyo- 
glossi muscles, which are, as you all know, a pair of fan-shaped 
muscles, attached to the inside of the chin, the middle line of the 
tongue, and the body of the os hyoides. This diagram will repre- 
sent it. Here is the muscle of the left side, and here is the right. 
When the patient puts out his tongue, this left half being paralysed, 
! and having lost its antagonism, the tongue obeys the action of this, 
the right half, and the fixed point of attachment of the muscle 
| being to the right of the mesial line, the base of the tongue is 
i brought forward, and to the right, and its point consequently 
! deviates to the left or paralysed side. It has been remarked, also, 
that there is some variety with respect to the paralysis of the 
tongue ; some patients can protrude it, others cannot. In some 
cases, too, the patient can put out his tongue well enough, but he 

28* 



322 



STOKES'S THEORY AND PRACTICE. 



cannot employ it in the articulation of sounds, and his speech is 
quite indistinct. 

I might occupy your time for several lectures with these sub- 
jects ; and, did my time permit, I could lay before you a vast 
quantity of interesting matter on the subject of paralysis from apo- 
plexy; but, as the number of lectures is limited, all I can hope to 
accomplish is, to point out the great landmarks to you, and leave 
the rest to your own study and experience. With respect to 
paralysis of the extremities, the upper are paralysed more frequently 
than the lower; and, when both extremities are engaged, the upper 
are generally more completely affected than the lower. When a 
person recovers, also, we find that the lower extremities are the 
first to regain their lost power and sensibility. These circumstances 
have been attempted to be explained by considering the particular 
parts of the brain in which the effusion has occurred ; but, as this 
has not as yet been sufficiently made out, I shall pass it over. I 
regret, also, that I have not time to enter into the subject of the 
different varieties of lesion of intelligence in cases of apoplexy. I 
must however observe that the varieties are infinite, and your trouble 
will be amply repaid by reading what has been written on this point 
by Dr. Abercrombie, and Dr. Cooke in his Treatise on Ner- 
vous Diseases. You will find in the latter work an extraordi- 
nary collection of facts with respect to lesions of the intellectual 
functions. 

I shall now endeavour to get through the treatment of apoplexy 
as briefly as the important nature of the subject will admit. 1 shall 
commence by saying, in the words of Dr. Abercrombie, that the 
remedies for apoplexy are few and simple. The great point is to 
relieve the head from the accumulation of blood, to prevent further 
congestion, and to obviate inflammatory action; and for these pur- 
poses the only efficient means we possess is bleeding. There is no 
disease in which the efficacy of free and bold depletion by the lancet 
is more remarkable than in apoplexy. I agree completely with Dr. 
Abercrombie in thinking that the symptoms which denote serous 
apoplexy by no means contra-indicate the use of the lancet ; for I 
have already shown, that serous apoplexy was nothing but con- 
gestion, that the serous effusion was one of the consequences of this I 
congestion, and by no means the cause of the apoplectic symptoms, 
Dr. Abercrombie thinks that, in the commencement of the disease, 
you may bleed where the pulse is feeble as well as where it is 
strong and full, and gives many important cases in which the dis- 
ease yielded to a copious abstraction of blood, though the state of 
the patient's pulse and general system at the time were such as would 
deter many from bleeding. He gives three cases of persons about 
seventy years of age, on whom this mode of treatment was prac- 
tised with success, and another of a person of spare habit, aged 
eighty years, whose life was saved by a bold and timely use of the 
lancet. There is also another case detailed of a patient who was 
worn down and dropsical at the time of the attack, and received 



APOPLEXY. 



323 



considerable relief from bleeding. I do not wish you to conclude 
J from this that you should bleed as boldly in the one case as in 
1 another; what I wish to impress is this, that in a vast majority of 
cases it is advisable to have recourse to the lancet. With respect 
to the first bleeding, I think that where the pulse is full and strong 
it should be large, and such as will produce some effect on the 
symptoms. This may be repeated afterwards to a smaller amount 
I if necessary ; but the subsequent bleedings should be rather local 
j than general, except where there is any renewal of the cerebral 
J and circulatory excitement, which must be always met with activity, 
j I believe the cases in which you must make the largest bleedings 
I are those in which there are symptoms of an hypertrophied heart. 
I But where this is not present, one or two bold bleedings, followed 
I by local depletion of the head, will be sufficient. In cases of apo- 
plexy, you may either open a vein or the temporal artery, for the 
! objections made to arteriotomy in phrenitis do not apply so much 
i to cases of apoplexy. There is no violence on the part of the 
j patient, nor is there the same chance of the vessel giving way. 
■ The head should be shaved and freely leeched, and the patient may 
I be cupped on the temples or the back of the neck. 

Next in efficacy to general and local bleeding seems to be the 
administration of strong purgatives. There are many cases on 
record in which the coma and other symptoms have resisted bleed- 
ing, both general and local, but have disappeared under the influ- 
ence of active purgation. One of the great objects in the treat- 
ment of apoplexy should be to get rid of the coma as soon as pos- 
| sible ; and for this purpose nothing appears to answer better than 
the early use of brisk purgatives. Dr. Abercrombie recommends 
croton oil as the best purgative that can be employed, and indeed it 
is an excellent one ; but if the patient can swallow, you need not 
be very anxious about the kind of purgative you prescribe ; any 
active purgative followed by a strong enema will do. Where the 
patient cannot swallow, you may mix the dose of croton oil with 
some mucilage, and pass it into the oesophagus by means of a gum- 
elastic tube. 

After purgation, the next thing is to apply cold to the head by 
means of cold lotions, or iced water, or by pouring a stream of cold 
water on the head. This is a measure of great efficacy, and one 
which you may employ with safety and advantage. 

In cases of apoplexy, where the coma has resisted free bleeding, 
both general and local, and where purgation and cold applications 
! to the head have been employed without any decided effect, it 
| seems advisable to apply a blister to the head or nape of the neck, 
j You will recollect that I told you that blisters were always danger- 
j ous in the early periods of all acute visceral inflammations. This, 
however, does not apply so much to cases of hemorrhagic effusion 
like apoplexy, in which blisters may be employed at an earlier 
period than in cases of active inflammation. I would advise 
you, therefore, to use blisters in cases of apoplexy attended by 



324 



STOKES'S THEORY AND PRACTICE. 



persistent coma, having first put into practice the means already 
mentioned. 

Many persons advise the use of emetics in apoplexy, but the 
facts bearing on this point, to which I have drawn your attention 
when speaking of inflammation of the brain, will also apply here. 
You may take it as a general rule, that where congestion of the 
head exists vomiting will always increase it, and must be therefore 
exceedingly dangerous. As far as theory goes it is totally against 
this practice, and I believe experience also is opposed to it. In a 
number of cases of disease of the brain, where emetics were em- 
ployed, it has been found that an unfavourable result ensued, and 
there are some cases of apoplexy on record in which the exciting 
cause was a fit of vomiting. 

Suppose that, after having taken away blood, purged actively, 
used cold applications, and blistered the head, the coma still re- 
mains, accompanied by a feeble pulse and cold skin, what are you 
to do? I believe, under these circumstances and these alone, you 
may venture on the use of internal stimulants. Though this is at 
best but a forlorn hope, still the practice appears rational ; we have 
analogy to guide us in the use of stimulants in such cases, and 
there are cases on record of persons who have recovered from this 
state by their judicious employment. The remedies most generally 
prescribed for this purpose are camphor, musk, and carbonate of 
ammonia. In the cases of typhus, we know that these remedies 
have frequently succeeded in removing the coma ; but I repeat, 
that you should never have recourse to stimulants until the period 
for depletion has passed by, and all the ordinary means have 
failed. 

I shall now suppose that- we have succeeded in removing the 
coma, that consciousness has returned, and that nothing remains 
but paralysis of one side. Our great object is to get rid of the para- 
lysis as soon as possible. Here you will recollect that you have to 
deal with paralysis depending on extravasation, a paralysis which, 
as far as we know, will not disappear under any form of treatment 
until the extravasated blood has been absorbed. The first thing 
then you have to do is to adopt measures to prevent a return of the 
attack. This is to be effected by carefully restricting the patient in 
his diet, by avoiding all causes of cerebral irritation, whether phy- 
sical or moral, and by obviating everything capable of exciting the 
circulation. But you should not be content with this: you should 
from time to time employ local depletion, which in cases of this 
kind has a double utility. It tends to prevent a repetition of the 
attack, and, by lowering the circulation, keeps the brain in that 
non-inflammatory condition which is most favourable towards pro 
moting the absorption of the coagulum. In many cases, also, you 
will find it of great advantage to establish a drain in the vicinity of 
the disease, and a great deal of good may be done by putting a 
seton, or an issue, in the neck. You must also pay constant atten- 
tion to the state of the bowels and urinary system in cases of para- 



APOPLEXY. 325 

] lysis ; keeping up a steady but mild action of the bowels has an 
excellent effect, and I need not impress upon you the necessity of 
paying strict attention to the bladder. 

The paralysis which supervenes on an attack of apoplexy, is to 
be treated always in the first place by means directed to the head, 
and the brain is to be put in such a state as will favour the removal 
of the clot by the means already recommended ; in addition to 
which it will be necessary that the body and extremities should be 
j kept in a warm temperature. But there is this very singular cir- 
i cumstance connected with some cases of paralysis, that a period 
I will arrive when, although the original disease of the brain has 
! been removed, and the clot absorbed, the paralysis still continues. 
It is not easy to explain the circumstance ; but it has been observed 
in many persons who have been paralytic, that the clot was com- 
pletely absorbed, and no existing trace of disease discoverable, such 
as would account for the continuance of the paralysis. In cases 
I like this we must adopt a different mode of practice, and have 
\ recourse to measures capable of exciting the brain, and we have 
reason to believe that whatever will excite the brain and restore its 
energy (I must use this phrase for the want of a better) will cure 
! the paralysis. We find that in some cases where the brain of a 
patient, under such circumstances, has been exposed to any sudden 
stimulus, whether physical or moral, the symptoms of paralysis 
have disappeared, sometimes gradually and slowly, at other times 
rapidly and at once. Now, this disappearance of the symptoms 
shows that the paralysis did not then depend on the presence of a 
I clot, for if an unabsorbed coagulum remained in the situation of the 
original extravasation, the paralysis would not disappear. But it 
has been frequently observed, that a patient, labouring under para- 
lysis, may get rid of his symptoms suddenly, or that, at a certain 
period, they begin to decline, and then go away altogether. From 
a consideration of these circumstances we are led to divide the 
treatment of paralysis of this description into two parts, and en- 
deavour first to excite the brain itself, and next the nerves which 
supply the paralysed limbs. For this purpose several remedies, 
supposed to be capable of stimulating the brain, so far as its action 
on the muscular system is concerned, have been recommended, the 
most important of which is the nux vomica, or its active principle, 
strychnine. The researches and experiments of modern medicine 
have already established the efficacy of strychnine in such cases, 
but you will recollect, as I before stated, that this powerful remedy 
can be employed with safety only in cases where the paralysis 
continues after the disappearance of organic disease of the brain. 
Until that period arrives, and all symptoms of congestion and 
j excitement are removed, it would be improper to prescribe the use 
, of strychnine. One of the most recent publications on this subject 
is from the pen of Dr. Bardsley of Manchester, in which you will 
find an exceedingly interesting series of cases treated with strych- 
nine, and^many of them with the most decided success. In most 



326 



STOKES'S THEORY AND PRACTICE. 



of these cases you will find that Dr. Bardsley, even where the 

disease has been of some standing, precedes the use of strychnine by 
measures calculated to deplete the head, even though the cases were 
chronic. Hence, whenever you are about to prescribe this remedy, 
you. should be satisfied that depletion has been sufficiently per- 
formed. You may be called to treat a patient for paralysis after 
an apoplectic attack. Here you must consider how far you are 
to premise the use of strychnine by depleting measures, and you 
must also reflect that we here have shadowed out one of the most 
important principles in medicine, that in almost all cases where a 
cure is to be attained, by stimulation, it will be effected more readily, 
and with much more certainty, when preceded by local depletion, no 
matter how long the disease may have lasted. The efficacy of strych- 
nine in paralysis seems to be dependent on the antecedence of local 
or general depletion. 

Strychnine being an exceedingly active remedy, and having a 
most powerful effect in stimulating the brain, it being also one of 
the accumulative class of medicines, it will be proper to commence 
its exhibition with a very small dose, and watch its effects with 
care. The following is the formula which I would recommend 
you to employ. You take a grain of strychnine, and your object 
being to divide it into a number of equal parts, (say sixteen,) to 
insure an accurate division, you dissolve it in a small quantity of 
alcohol, and, having mixed this solution with a sufficient quantity 
of bread crumb or conserve of roses, you divide it carefully into 
sixteen equal pills. In this way you may be tolerably certain that 
each pill contains one-sixteenth of a grain. Begin at first with one 
pill a day, next day you may give two, and so on until you have 
brought it up to half a grain or a grain, watching carefully its 
effects. Now, what are these effects '\ They are very analogous 
to the phenomena produced by inflammation of the brain taking 
place in the vicinity of the clot, namely, spasms of the muscular 
system. 

It is also a curious fact, that these spasms are principally observed 
on the paralysed side ; in other words, that the portion of the brain 
which has been affected by disease is more sensible to the stimulus i 
of the strychnine, the consequence of which is spasmodic twitches I 
in the paralysed limbs. The great nicety of practice in the treat- 
ment of paralysis in this way, is to keep up a certain degree of this 
irritation without letting it proceed to any degree of violence, and 
to omit it whenever the following symptoms become manifest — 
headache, giddiness, weakness and sickness of the stomach, and too 
violent spasmodic twitches of the limbs. 

There is a great difference with respect to susceptibility of the 
effects of this remedy in different individuals ; in some the effects 
speedily appear, and you are obliged to intermit its use ; others will \ 
bear large doses for a considerable time, and you may push the 
strychnine until a grain or a grain and a half is taken in the day. ji 
I have myself given to one patient a grain every day for the space 



PARALYSIS. 



327 



of a fortnight without any intermission. In all cases, however, it 
will be necessary to watch the symptoms. There is one effect of 
strychnine which appears to be unfavourable, and whenever it oc- 
curs you should either omit the medicine or diminish the dose. 
Along with or succeeding the spasms, there is a tonic rigidity of the 
limbs ; when this occurs you should be cautious in the administra- 
tion of strychnine. The length of time which it should be con- 
tinued will of course vary according to circumstances, but you 
should be aware that it requires a considerable period of time to 
produce its effects. In all Dr. Bardsley's cases, and in all those 
treated at the Meath Hospital, it has been continued for a consider- 
able time, certainly more than a month. It is also necessary for 
you to recollect that strychnine is one of those medicines which are 
termed accumulative, that is to say, remedies the operation of which, 
after remaining latent for some time, suddenly explodes with great 
violence. When this occurs, the strychnine must be immediately 
given up, and steps taken to control its effects. One of the best 
things for this purpose is the carbonate of ammonia with some mild 
anodyne. I have seen very severe spasms from the use of this me- 
dicine. In one case these spasms were so violent as to roll the 
patient nearly out of bed. 

It has been proposed to employ brucine as a substitute for strych- 
nine. Of this remedy I can say but very little ; I have given it but 
very seldom, I believe in only two cases, and in these without any 
sensible effect. It is much weaker than the former remedy, one- 
fourth of a grain of strychnine being equal to six grains of bru- 
cine. Other remedies have been proposed for the same purpose, 
among the rest, iodine, which has been recommended by Dr. 
Mansfield. 

The next class of remedies are those which are employed for the 
purpose of exciting the nerves of the paralyzed limb. As my time, 
however, has expired, I must postpone the consideration of these 
until our next meeting. 



LECTURE XXXI. 

Local treatment of paralysis — Flesh-brush, shower-bath, &c. — Application of moxa— 
Cases in which it is useful — Professor M'Namara's plan — Acupuncture with galva- 
nism — Electro-puncturation — Method of applying — Powerful action of small battery 
— Mr. Hamilton's observations — Value of galvanism and electricity — Use of, in para- 
lysis of the muscles of the face— Paralysis from disease of the arterial system — Case 
of, by Dr. Graves — Diagnosis of this affection — Pathology of Pott's gangrene — Du- 
puytren's mode of treatment. 

Having spoken of the general treatment of paralysis after apo- 
plexy, we come now to the local management of the disease, or that 
portion of its treatment which consists in the application of stimu- 
lants to the nerves and their origins. Local stimulation of paralytic 
limbs may be performed in a variety of ways ; all the usual stimu- 



STOKES'S THEORY AND PRACTICE. 



lant embrocations may be employed for this purpose with the best 
effects. I shall not take up your time in detailing the different 
kinds of liniments which are used on such occasions ; they are 
universally known, and may be varied ad infinitum. The flesh- 
brush, the shower-bath, either tepid or cold, occasional blisters to 
the spine, or along the course of the nerves, croton oil and terebin- 
thinate frictions— all these are measures that may be employed with 
advantage. The use of the moxa has been also strongly recom- 
mended, and appears to be decidedly beneficial. The efficacy of all 
these remedies, however, seems to depend chiefly on the particular 
stage and nature of the disease, and hence their good effects are 
most apparent in those cases where the paralysis no longer depends 
on organic disease of the brain, but seems to be connected with 
that peculiar state of the nervous system which arises from a long 
interruption of the power of transmitting volition. It is in cases 
like this that the application of the moxa has been found to produce 
the most favourable results. Where the lower extremities are 
affected, it may be applied over the sciatic nerve on the loins, or a 
little below ^ind to the outer side of the popliteal space over the 
track of the peroneal nerve. In case of paralysis of the upper ex- 
tremity, you may apply it to the back of the neck, or in the neigh- 
bourhood of the brachial plexus. 

A gentleman who does me the honour of attending these lectures, 
has related to me the particulars of a remarkable case, which I 
shall mention en passant. A young female was subject to repeated 
violent attacks of spasms with contraction in one of the upper 
extremities. She had laboured under this affection for a long time, 
and tried various remedies without benefit. At the suggestion of 
this gentleman she tried cupping in the neighbourhood of the 
shoulder and brachial plexus, and found that it produced decided 
relief to the symptoms. In this case it is highly probable that the 
disease was seated in the brachial plexus, and had no connection ; 
with the brain, for it had continued for a great length of time (more j 
than three years, I believe) without any remarkable variation in 
its symptoms. If the spasms of the arm had been produced by 
irritation of the brain, she would in all probability have had para- j 
lysis long before this period; this, however, did not occur, and the !| 
probability that the disease was seated in the brachial plexus is j 
still further confirmed by the fact, that the spasms were relieved by 
local bleedings. Here we have the spasms relieved by antiphlo- 
gistic means, but in a case of atony of the same nerves most benefit 
would be derived from the use of stimulants. The more com- 
pletely the paralysis is of this description, the more sure will be the 
effects of local stimulation. You will sometimes meet with cases 
of paralysis from pressure on the nerves without organic disease. | 
Thus there is a case on record of a person who lost the use of one 
of his upper extremities, from having leaned too long over a bench 
at a public meeting. I recollect the case of a man, who during a ; 
fit of intoxication feel asleep with his arm thrown over the back of 



PARALYSIS. 329 

a chair, and awoke with perfect paralysis of the hand. Cases like 
these are seldom of long duration, and are much improved by the 
, application of the moxa. I may state, however, that permanent 
paralysis has been induced in this way. The best way of using 
the moxa is, not to make a deep eschar, but to touch the parts 
slightly, and repeat the application frequently. In the case of 
paralysis of the hand, immediate relief followed the use of the moxa 
to the back of the wrist. 

While on this subject I may advise you always to employ the 
' moxa in the mode first, I believe, devised by my friend and col- 
league, Professor M'Namara. The top of the moxa is to be dipped 
! in a strong solution of the oxymuriate of potass, which is to be 
j allowed to dry upon it. The moxa being fixed to the part by a 
little gum, a drop of strong sulphuric acid will produce immediate 
I ignition. In this way you prevent all the alarm which the patient 
feels at seeing a lighted candle brought to the bed-side. The same 
1 rule is to be observed when you employ electricity, the best mode 
of using which is to place the patient on an insulated stool, and 
| draw sparks from, or shocks through, the affected limbs. Elec- 
tricity frequently does much good in such cases; but, in order to 
' obtain decided benefit from it, you must persevere for some time in 
its employment. It has been lately proposed to employ the stimulus 
of electricity and galvanism in a different way, by transmitting it 
directly to the muscles of the affected limbs by means of needles, 
which are to be inserted into different parts of paralysed extremities, 
and which are intended to act as conductors for transmitting the 
I galvanic influence. This has been termed electro or galvanic 
puncturation, and forms an excellent mode of applying the stimulus 
of galvanism. I have made many experiments as to its effects, to 
which I shall briefly direct your attention. 

The first thing to be considered is the manner of its application. 
The following is that which I use at the Meath Hospital : — Having 
procured two fine sewing needles, your first step will be to take 
the temper out of them ; for, if you employ them in the tempered 
state, you will run the risk of their breaking in the flesh, and this 
would be very disagreeable. You can easily take the temper out 
of them by holding them in a candle until they become red hot, 
and then, letting them cool gradually. The next thing is to place 
i a head which will remain firm on the needle, and for this purpose 
you pass a small portion of thread through the eye, and then cover 
it with a bit of melted sealing wax. Having thus formed a head 
for the needle, you sharpen its point, and polish it by the emery 
pincushion, and the sharper it is the better. There is nothing 
more simple than to introduce the needles. You make the part of 
! the skin tense with your finger and thumb, where you intend to 
j introduce them, and, placing the point of the needle perpendicularly 
| on it, you press it downwards in a slanting direction, using, at the 
I same time, a rotatory motion, and thus easily pass it in ; when you 
I have pierced the skin and fascia, there is no difficulty in introducing 



i 



330 



STOKES'S THEORY AND PRACTICE. 



it into the muscular fibres. The distance between the needles must 
be regulated according to circumstances. You then proceed to 
send the galvanic fluid to the part, and, for this purpose, the best 
mode is to employ a small galvanic battery with a limited number 
of plates. If you have plates of from two to three square inches 
you will find that from fifteen to twenty of these, in a state of 
ordinary action, will be quite sufficient, particularly in the com- 
mencement of the treatment. It is a curious fact, that the intensity 
of the shock is increased to an extraordinary degree by means of 
the needles. A battery which in the usual manner would not com- 
municate any shock, will, when used with the needles, give a 
violent one, and communicate such a stimulus to the nerves as will 
throw the whole limb into violent spasms, and cause a copious 
perspiration to break out over the body. I have seen very great 
effects from a feeble battery in this way, and it would "appear that 
this is the result of the direct transmission of the galvanic influence 
to the muscular fibre. In most cases a perspiration is brought on, 
the limb convulsed, and sometimes the whole body is thrown into 
spasms. As an illustration of the power of the battery when used 
in this way, I shall mention the following case: — A patient who 
was under the care of Mr. Hamilton, laboured under amaurosis ; 
he was anxious to try the effect of galvanism, and with this view 
inserted one needle in the upper part of the back of the neck, and 
another over the orbit, so as to direct the course of the fluid across 
the base of the brain. He intended at first to use a small battery 
of twenty-five plates, but it struck him that even twenty-five might 
be too much. He made the experiment with three pairs of plates, 
and, the shock being given, the patient, to his astonishment, fell 
back as if he had been stunned by a violent blow on the head, and 
remained for nearly a minute in a state of insensibility. In other 
cases, too, where the galvanism was applied in the vicinity of the 
head, I have found that severe headache, giddiness, and even a 
stiffness of the muscles of the face, were produced ; all showing its 
powerful action on the nervous centre. 

Some singular circumstances connected with this subject were 
observed in the Meath Hospital. It was found that after a certain 
number of shocks had been communicated to the parts, when you 
came to withdraw the needles there was a very remarkable differ- 
ence in the ease of removing them. The needle through which 
the positive galvanic influence had been transmitted, was found to 
be strongly fastened in its situation, while that to which the nega- 
tive pole had been applied, slipped out with the greatest ease. 
This result was constant. In some cases, where half a dozen 
shocks or so have been given, the extraction of the positive needle 
has been only accomplished with considerable pain to the patient. 

It has been suggested by a distinguished scientific friend of 
mine, that this results from the coagulation of albumen at the 
positive pole. Mr. Hamilton, however, who performed most of the 
operations for me, thinks that the true explanation is the paralysing 



PARALYSIS. 



331 



effect of the negative pole on the muscular fibre, while the positive 
needle is firmly grasped by the increased contraction. Further 
researches are necessary on this point. Another fact connected 
with this subject is, that when the needles have been inserted into 
a large muscular mass, the positive needle is powerfully retracted, 
and carried, as it were, into the muscles. In one case, where 
the needle was inserted into the lumbar muscles, in a patient 
labouring under sciatica, more than one-twelfth of an inch of it 
was drawn in at each shock; so that, after a certain number of 
shocks, it passed up to the head. This is one reason for using the 
sealing-wax head, in order to prevent the complete passing in of the 
needle. 

With respect to our experience of the value of this mode of 
employing electricity or galvanism, I have to remark that, if gal- 
vanism or electricity can be of any use to paralysed limbs, this is 
one of the best modes in which it can be applied. The apparatus is 
simple, can be prepared in a moment, and does not depend on the 
state of the weather, like the ordinary electrical machines. There 
is another advantage, also, it is not so likely to excite alarm in the 
mind of the patient. We have employed it in several rheumatic 
and paralytic cases in the Meath Hospital, but have not as yet 
been able to say that decided benefit has accrued from it to the 
i majority of the patients on whom it has been tried. This is more 
particularly true with respect to paralytic patients ; in the rheu- 
matic cases we have found it more beneficial. In a remarkable case, 
where the deltoid muscle was paralysed and atrophied from some 
affection of its nerves, Mr. Hamilton tried it for a fortnight without 
any good effects. In a case of senile amaurosis, its effect was to 
produce flashes of light before the eyes, lachrymation, and contrac- 
tion of the pupil, but after a fortnight's trial there was no improve- 
ment in the sight. We have had, however, distinct and unequivocal 
proofs of its value in one case of paralysis of the muscles of the face, 
which had all the characters of that described by Sir C. Bell, as 
resulting from an affection of the seventh pair of nerves. I have 
not the notes of this case at present, but shall bring them down 
and lay them before you on to-morrow. I may however observe, 
at present, that this patient had been for a long time labouring 
under an affection of one side of the face, and had used a variety 
of remedies. Those principally employed were stimulating lini- 
ments and the internal use of strychnine, from which he derived 
some slight benefit; but the application of the galvanic fluid, in 
the way I have mentioned, was followed by decided and rapid 
! improvement. Indeed, from the time it was first applied, the 
patient recovered rapidly, so that in a very short time all the 
I deformity of face disappeared. Now the value of the application 
I is to be estimated in this way. Here we have a case of paralysis' 
; of a local nature, and not depending upon any disease of the brain; 
i 1 in this case the galvano-puncturation was tried, and found to be 
most beneficial. The conclusion, then, as far as a single case goes, 

I 



I 



STOKES'S THEORY AND PRACTICE. 



is, that this mode of treatment is best adapted to the form of para- 
lysis just mentioned, in which we find an affection of some of the 
muscles remaining after the original disease of the brain has been 
removed. The same observation, I need not tell you, applies to 
all other remedies which are employed for the purpose of local 
stimulation. 

Before I leave the subject of paralysis, there are two points to 
which I wish to call your attention. One of these involves the 
consideration of a remarkable form of paralysis in which the dis- 
ease appears, as far as we can see, not to depend on any primary 
lesion of the nervous system. In this form we have a paralysis, 
not the result of any disease of the brain or nerves, but connected 
with an affection of the vessels of the part. This is a very singular 
disease, and I am anxious you should be acquainted with it, for I 
believe it is by no means so rare as many persons think. The 
other point to which I would direct your attention refers to the 
influence of magnetism on the human body ; of this I shall speak 
on a future occasion, confining myself for the present to that 
form of paralysis which is connected with disease of the vascular 
system. 

So as to give you some idea of this affection, I think I cannot do 
better than read for you the notes of a case of it, published by 
Dr. Graves and myself in the fifth volume of the Dublin Hospital 
Reports. 

A man, aged 44 years, was attacked in December, 1828, with 
alternate sensations of cold and burning heat in the toes of the right 
foot. These extended to the leg, of which the power became 
diminished. Pains in the foot next occurred, and in a month the 
part became cold and wholly deprived of sensation. 

On the day of his admission the pain suddenly extended to the 
calf of the leg ; and from this time he lost all power of motion in the 
leg. On admission, the temperature of the body, with the excep- 
tion of the affected limb, was natural. The pain had extended to 
the thigh during the night. The temperature of the limb was but 
58° of Fahrenheit. Slight oedema existed about the ankle. There 
was complete loss of sensation from the middle of the thigh to the 
toes ; the patient could rotate the thigh slightly, but there was no 
other voluntary motion possible. The femoral artery appeared 
like a hard cord, painful on pressure, and without pulsation. By 
the stethoscope we found that pulsation was also wanting in the 
common iliac on this side, while that of the left iliac was plainly 
perceptible. The patient died on the fourth day after admission, 
the limb having become purple, tender, and covered with vesica- 
tions. 

On dissection, the right common iliac appeared distended and 
livid, and was completely plugged up by a dark clot, extending to 
the external and internal iliacs, and engaging the gluteal and 
obturator arteries. The same occurred in the femoral and pro- 
funda, and extended, as far as they could be traced, to the tibial 



PARALYSIS. 



333 



arteries, and to the peroneal. The lining membrane of these 
vessels was soft, villous, and red ; the clot in some places being 
separated from it by a layer of puriform matter. No disease in the 
veins. A large portion of the vasti and rectus muscles was white 
and hardened. Here you perceive a train of symptoms, some of 
which might be referred to disease of the brain, if the man had 
any cerebral symptoms, which was not the case, for his intellect 
was sound, and he had no evidence of cerebral disease except the 
paralysis. 

His constitutional symptoms were emaciation, prostration of 
strength, and loss of appetite. The temperature of the body was 
natural, but, on examining the limb, we found (and this is a point 
of great importance) that it was as low as 58° of Fahrenheit ; in 
fact, it was quite cold. There was also complete loss of sensation 
from the middle of the thigh to the toes, and though he could 
rotate the limb slightly, it was, in all other respects, powerless. 
Here we have paralysis of motion and sensation in one of the 
extremities, with remarkable coldness of the limb. On making 
I an examination along the track of the femoral artery, we found 
' that it was painful on pressure, without any pulsation, and con- 
veying to the finger the feel of a piece of hard cord. From a con- 
sideration of those circumstances, we came to the conclusion that 
it was not pervious, and that this would account for the state of 
the limb. In this case, also, we made another remark, and this, I 
believe, is the only instance on record in which such a diagnosis 
was made. Up as high as the groin the pulsation of the femoral 
! artery could not be felt, and we were anxious to ascertain how 
far further the disease extended. The state of the femoral artery 
in the left groin was natural. On making an examination with 
the stethoscope, we found that the pulsations of the aorta were 
perceptible down to its • bifurcation, but when the stethoscope was 
applied below this on either side, we observed that there was no 
pulsation in the right common iliac artery, but on the left side it 
could be traced distinctly down to the groin. Here then we had a 
train of phenomena, such as ordinarily occur in paralysis affect- 
ing the right lower extremity, and along with this an obstruction 
to the circulation in the thigh and leg. From these circumstances 
we made the diagnosis of obstruction of the right iliac and femoral 
arteries. On dissection, we found that the aorta was healthy to 
within about six inches of its bifurcation ; below this point it was 
partly filled by a red clot. The left common iliac was healthy, 
but the right was plugged up with a dark red clot, which extended 
into the external iliac and obturator arteries, filling up also the 
• femoral and its branches. The case, in fact, was nothing more or 
| less than one of chronic arteritis. 

This remarkable form of disease has been also observed by other 
; authors. You will find it well described in Rostan's work on 
j diseases of the brain, where he mentions that this loss of sensation 
| and motion in a limb is sometimes produced by obstruction of its 

29* 



334 



STOKES'S THEORY AND PRACTICE. 



vessels. In persons advanced in life, the arteries are also frequently 
obstructed by the formation of ossific deposits within them, pro- 
ducing loss of power, coldness, and diminution of sensation, as in 
the foregoing case. A similar effect may occur from the pressure 
of an adjoining tumour on the trunk of a principal artery. 

Paralysis resulting from disease of the arterial system is distin- 
guished from paralysis caused by cerebral disease, by the following 
marks ; first, by the colour of the integuments of the affected limb, 
which, in a case of the former description, are generally of a violet 
hue, or of a much deeper tinge than in the latter case, or in a state 
of health. It is very rare to find the two limbs of the same colour, 
as we do in cases of cerebral paralysis. Another mark is, that the 
temperature of the limb is always lower than that of the healthy 
one ; but the distinctive sign of this form of paralysis is the absence 
of pulsation in the arteries in paints where it should be naturally 
observed. If to this description you join the absence of cerebral 
symptoms, you will seldom fail in making a correct diagnosis. I 
have had two cases of this disease under my care ; one of them 
occurred in the upper, the other in the lower extremity, and, from 
observing the characteristic marks already detailed, I had no diffi- 
culty in making the diagnosis. It is to that peculiar form of this 
disease, which is considered by some authors to depend on ossifi- 
cation of the arteries, that the name of " Pott's gangrene" has been 
applied. A great deal of light has been thrown on this disease by 
the researches of modern pathology. It is now pretty well esta- 
blished that we may have this gangrene, not only in old persons 
from ossification of the arteries, but also in the young from arteritis. 
In truth, the pathology of Pott's gangrene appears to be one of two 
changes — either an arteritis or ossification of the arteries them- 
selves; and of these two causes the first is by far the most frequent. 
You will see at once the importance of this view of the question, 
for if the gangrene occurs in a young person, and is connected 
with inflammation of the arteries, it is a disease more or less under 
the control of medical treatment; but if it be produced by ossifica- 
tion of the arteries, the results of treatment are far less likely to 
be successful. 

We have, then, in a case of paralysis of this description, more or 
less loss of sensation and motion, coldness of the limb, and absence 
of arterial pulsation. With respect to coldness, it may be said that 
it is of little value as a sign, being frequently observed in cases of 
cerebral paralysis. To this it may be replied, that though coldness 
is sometimes present in cases of ordinary paralysis, still it is never 
so remarkable as in this form of the disease, and the temperature of 
the limb is but a few degrees below the standard of health. Dr. 
Abercrombie makes a very interesting conjecture on this subject. 
He says the temperature of paralysed limbs is generally considered 
to be lower than that of the healthy ones, and, indeed, such is the 
case; but the true explanation of this occurrence is, that in this 
condition the limb loses its power of preserving a medium tempera- 



PARALYSIS FROM ARTERIAL DISEASE. 335 



ture, and hence it is, that, according to the temperature to which it 
has been exposed, it becomes hotter or colder than the healthy 
limb. A case is mentioned, of a medical man who laboured under 
paralysis of one of the upper extremities. This gentleman, on one 
occasion, after having applied some warm bran to the paralysed 
limb, was astonished to find, on touching it with the sound hand, 
that he could not bear the heat, though he was at the same time 
unconscious of any increase of temperature in the paralytic ex- 
tremity. 

The symptoms, then, of this form of paralysis are, diminution or 
abolition of sensation and the power of motion, a dark or violet hue 
of the skin, remarkable coldness, and absence of pulsation in the 
arterial trunks which supply the affected limb. These, with a 
tendency to the formation of gangrene, are the characteristic marks 
of the disease, and, by bearing them in mind, you will seldom err 
in making a diagnosis. In the great majority of cases the disease 
is confined to one extremity ; but Rostan gives some cases in which 
it was more general. We might also add to the diagnosis, that 
paralysis connected with disease of the brain often comes on sud- 
denly, while in this case its invasion is slow and gradual. It is 
however true, that some cases of paralysis, depending on this cause, 
have come on so suddenly as to render this circumstance of less 
value as a diagnostic. 

With respect to the treatment of this form of paralysis, if the 
patient be young and the disease recognised at an early stage, it is 
possible that you may be able to arrest it by free local depletion and 
other antiphlogistic means. In the case which was under treat- 
ment in the Meath Hospital, the symptoms had lasted for a consi- 
derable time before the disease exhibited any remarkable violence. 
The man was admitted on the 7th of February, and at this time the 
disease had been five weeks in existence, having begun at the lower 
part of the limb, and extended gradually upwards until it involved 
the whole leg and thigh. Yet it is very probable that this patient 
might have been saved, if proper means had been taken to arrest 
the inflammation of the vessels at an early period. Baron Dupuy- 
tren has published a case, in which it appeared that this disease was 
setting in, but was checked at once by bold antiphlogistic treatment 
directed to the affected limb. 



LECTURE XXXII. 

Paralysis from arterial disease — Singular cases of, by Rostan — Diagnosis of paralysis 
from arterial obstruction — Magnetism, use and action of — Effect of magnetism in 
disease — Result of trials in the Meath Hospital — Paraplegia — Mechanical hypere- 
mia — Occurrence without disease of the cord or vertebrae — Cases by Mr. Stanley — 
Effects on urine by division of the spinal cord — Ammoniacal urine — Caries of the 
vertebrae — Diagnosis of paralysis with disease of the kidney — Prognosis in para- 
plegia — [Dr. Graves's views and cases of paraplegia — A sequence of fever — Means 
of prevention and cure — Local injury to a nerve causing partial paralysis.] 

j At my last lecture I spoke of that form of paralysis which de- 
pends on arterial obstruction, and mentioned, as one of the principal 



336 



STOKES'S THEORY AND PRACTICE. 



diagnostics, a remarkable coldness of the diseased limb. I quoted 
for you a passage from Dr. Abercrombie's work, in which he sug- 
gests that jt is probable that the actual condition of paralytic limbs, 
in the usual acceptation, so far as temperature is concerned, depends 
upon their having lost that power which animal bodies possess of 
preserving a medium temperature ; so that their temperature be- 
comes elevated or lowered, according to that of the surrounding 
matter. The general rule in cases of this description is, that the 
temperature of a paralysed member is a little lower (say two or 
three degrees) than the rest of the body ; but when we find a limb 
reduced to the temperature of 58°, as in the case I mentioned, it is 
quite a different thing, and, under such circumstances, the great 
probability is, that the paralysis is connected with arterial obstruc- 
tion. 

You will see, in Rostan's works on the Softening of the Brain, 
the reports of two cases of this disease, occurring in patients of ex- 
tremely advanced age. In one, there was complete paralysis of 
the right arm, which was cold and livid. The fingers were threat- 
ened with gangrene, and no pulsation could be felt in the radial 
artery. By stimulating frictions, a certain degree of warmth and 
motion was restored, and it was even thought that pulsation could 
be perceived. By degrees, the power of the left arm, and of the 
lower extremities, began to fail, with diminution of the force of the 
pulsation. On dissection, extensive disease of the arteries was 
found ; the right brachial, at the insertion of the deltoid, was oblite- 
rated by a mass of fibrin, below which the vessel was contracted 
and closed : the left brachial artery was also narrowed, but without 
any clot ; and this condition was further met with in the crural 
vessels. The cerebral arteries and the aorta were diseased. In the 
second case, the patient, aged SO, was attacked with violent pains 
in the left leg, which became cold and bluish. There was no lesion 
of intelligence, and the corresponding arm was unaffected. In 
fifteen days, the pains having augmented, a certain degree of para- j 
lysis supervened, which, however, was never complete. On dis- , 
section (the disease having lasted a month), the crural artery was j 
found extensively obliterated by a fibrinous clot. Here you observe 
that, notwithstanding the great age of both patients, the disease was f 
not ossification, but, in all probability, arteritis. \ 

At our last meeting, I forgot to mention the particulars of a case, , 
bearing on this part of the subject, and which goes to prove that - 
even complete coldness of the affected limb is not, in itself, sufficient \\ 
to establish the diagnosis of paralysis from arterial obstruction. I 
have had lately under my care, a gentleman who has been for the 
last four or five years labouring under paralysis of the lower extremi- 
ties, unaccompanied by any symptoms indicating disease of the 
brain. His intellect remains not only unimpaired, but in a state of 
high activity : and, what is equally singular, he has had none of the 
usual symptoms of disease of the vertebras or spinal cord. His \l 
limbs, however, are quite powerless, and are of an icy coldness ; 



PARALYSIS FROM ARTERIAL DISEASE. 337 

and yet you will hardly believe me, when I tell you that I have re- 
peatedly felt the femoral, popliteal, and even the anterior tibial 
! arteries, pulsating distinctly. This is a singular fact, but I have 
verified it by a number of observations. You will perceive, then, 
that in taking a remarkably diminished temperature as a diagnostic 
of paralysis from arterial obstruction, we must admit that, as a sign, 
it is only valuable when combined with absence of arterial pulsation. 
In this case, the fact of such extreme coldness of the lower extremi- 
! ties, at the same time that their circulation continues with undi- 
! minished activity, becomes of great importance, as tending to prove 
that the temperature of the body depends more upon the state of in- 
■ nervation than on arterial action. There are, indeed, many facts 
| which go to prove that animal heat is more closely connected with 
the nervous system than with the circulating. 

I spoke of the employment of electricity and galvanism in the 
local treatment of paralysis. While on this subject, I shall take an 
opportunity of briefly drawing your attention to the use of mag- 
netism in certain cases of nervous disease. Here let me be under- 
stood, I am not going to lecture on animal magnetism ; it is, at 
| present, a theme unsuited for the practical physician ; no one more 
firmly disbelieves, no one more thoroughly despises, than I do, the 
countless absurdities which have emanated from the imaginative 
disciples of animal magnetism. But as in almost every human hy- 
pothesis there is a fraction <ff truth, so in the doctrines of animal 
magnetism there is, perhaps, something which may not be entirely 
visionary: and it is possible that there may be some modification 
of the nervous influence, communicable from one person to another : 
\ this is one of the doctrines of animal magnetism. Another leading 
doctrine is, that organs, which are adapled by nature for the dis- 
charge of some peculiar function, appear in their magnetised state 
to take on a new function. Now, without saying that we are to 
believe in this, or in the extraordinary romances which are given 
in illustration of it, still it is right to admit the possibility of its 
occurrence, to a certain degree; because we frequently observe, in 
pathology, many instances of organs taking on functions, not 
merely new, but even totally repugnant to our ideas of their struc- 
tural arrangements. We may, then, I think, without going too far, 
admit the possibility of a communication of some modification 
of the nervous influence from one person to another, and that 
organs under this influence may take on new functions; but, in 
j the present state of this subject, this is as far as we can go. 

But we have to deal, at present, with a more tangible and im- 
portant subject — namely, the action of magnetism, in its proper 
acceptation, on the human body. You are aware that the term 
\ animal magnetism was first applied to the results of certain 
i effects on the human system, which were supposed to be brought 
i about by the aid of metallic contact ; and you are all acquainted 
I with the history of the metallic tractors. The term magnetism, 
j however, is totally inapplicable to the communication of nervous 

If 



338 



STOKES'S THEORY AND PRACTICE. 



influence from one individual to another ; nor have we any grounds 
for connecting such phenomena with magnetism, in its proper accep- 
tation. 

That a magnet should act on the human body, is neither extra- 
ordinary nor incredible. You know that electricity, and its modi- 
fication galvanism, have a powerful influence on the system ; and 
modern researches have shown that there is a close connection, if 
not an absolute identity, between electricity and magnetism. 
Now, on this subject of magnetism, the researches of some eminent 
men have been, latterly, employed, and the results of their labours 
have been received by some with an undistinguishing credulity, 
and by others with unphilosophical skepticism. One of the prin- 
cipal things which has prevented medical men from entering on 
this subject is, that many persons have confounded the results of 
magnetic action on the human body with the absurdities of animal 
magnetism and metallic tractors. There is, however, I need not 
repeat to you, an essential difference between them. In the Meath 
Hospital I have lately made a number of experiments, with a view 
to ascertain the effects of a powerful magnet on the human body. 
The magnet which I used, was one of considerable power, being, 
in its highest state of action, capable of supporting a weight of 
more than twenty pounds. Now, in almost every instance where 
this instrument was used, we found that, when brought near to 
sensible surfaces, phenomena were*produced which were very 
similar, indeed, to those of electricity. These phenomena also 
appeared in so many cases, and with such a remarkable constancy, 
that they could not be accounted for by any supposition of accident. 
We have applied it in cases of rheumatism, sometimes to a healthy 
part of the body, sometimes to the part affected. In one of these 
cases, the application of the magnet was followed by a very rapid 
subsidence of the morbid symptoms, and the patient got well in a 
few days. Here let me remark, that there is no one more opposed 
than I am to the publication of the result of a single case as a proof 
of the success of any particular remedy; and, in putting forward 
this case, I do not wish it to be received as an instance of a decided 
cure of rheumatism by magnetism. The only reason why I quote 
it, is, because in other cases of rheumatism we had distinct 
evidence of the influence of the magnet to a greater or less extent. 
The patient, a stout man, of good constitution and in the prime of 
life, was brought into the hospital for an attack of rheumatism in 
the back and left shoulder, which had come on after exposure to wet. 
The first seizure was three days before admissions When brought 
in, he had severe pain in the back and shoulder, increased on 
pressure ; he could neither elevate his arm to his head, nor could 
he bend the head towards the shoulder, without great difficulty 
and suffering. The value of this case consists chiefly in this, that 
except using the magnet there was no other remedy employed j if ; 
any other medicinal agency had been used, it would have been 
difficult to attribute the merit of the cure to magnetism. I applied, 



PARALYSIS FROM ARTERIAL DISEASE. 339 

|* 

| in this case, the large magnet to the shoulder, within a short dis- 
! tance from the skin. In about half a minute the patient remarked 
that he felt a kind of pricking sensation immediately under the 
magnet ; this was succeeded by a feeling of heat in the part, 
which became increased by continuing the application, while at 
the same time the pain was sensibly relieved. The sensation of 
warmth continued in the shoulder for about ten minutes after the 
1 magnet had been removed, and the patient declared that he received 
| great benefit from the application. On the following day, the 
; magnet was applied again with precisely the same results ; the 
I same thing was done on the third day, when the pain was very 
■ much reduced, and the arm became more moveable. On the 
fourth day, the mobility of the limb was increased, and he could 
bend his head in the direction of the shoulder with very little 
inconvenience. On the eighth day, the power of motion was 
restored, the pain gone, and the patient left the hospital quite well. 
I have heard nothing of him since ; but if he had not experienced 
permanent relief, it is very probable he would have returned again, 
| for he seemed quite pleased with his treatment. If this was the 
only case in wmich the magnet had been employed, it would prove 
nothing either for or against its use. It might be said, that the 
cure, in this instance, was the result of keeping the patient in a 
j warm bed, and that any good, supposed to be effected by the 
magnet, might be attributed to the influence of imagination. But 
to this it may be answered, that the sensations observed by this 
patient were exactly the same as in others, each having noticed 
1 the peculiar pricking sensation in the part to which the magnet 
was applied, and the subsequent feeling of warmth. Again, it is 
to be remarked, that although the symptoms in this case were 
severe, the cure was extremely rapid; and when you recollect the 
obstinacy of most affections of this kind, you must allow that a 
week was a very short space of time for its accomplishment. 

The following is another equally interesting case. A woman 
was admitted into the Meath Hospital, labouring under paralysis of 
the right side of three weeks' standing. The history of her case 
was, that she had fallen into a state of mental despondency, after 
the death of her husband, "who was her only support ; she then got 
symptoms of derangement of the stomach, and hypochondriasis, 
followed by an attack of paralysis, which deprived her of the power 
of using one side. On examination, we found that, as far as 
motion was , concerned, the paralysis was not complete, but that 
there w 7 as a total loss of sensation in the side affected. I was 
curious to observe what the effect of the magnet would be, and 
accordingly applied it to the spine, moving it upwards and down- 
i wards along the cervical and dorsal regions, at about half an inch 
I from the surface. After it had been applied for a few seconds, she 
j remarked that she felt a sensation " of wind" passing over the left 
i shoulder, but not over the right. Observe, it was on the right side 
I of the body that the paralysis existed in this case ; and you will 

I 



310 



STOKES'S THEORY AND PRACTICE. 



also recollect that it was chiefly a paralysis of sensation. Now, it 
is quite contrary to chances that she should have described it in 
this way, if she had not really felt it in this situation. The action 
of the magnet was naturally felt on the left, which was the sensible 
side, for, on applying it to the opposite or paralysed side, she said 
she no longer felt the sensation of " the wind." During the opera- 
tion, she saw the instrument ; and if disposed to draw upon her 
imagination for a description of her sensations, she might say that 
she felt the aura on the paralysed side ; but this was not the case, 
for she stated that it was no longer perceptible, when the magnet 
was moved from the sound to the paralysed side. In this case, I 
must tell you that magnetism was not the sole remedial agent 
employed, for she had been also leeched and blistered. She was 
admitted on the 12th of August, and on the 17th of the same 
month, the power of motion in the upper extremity was so much 
increased, that she could grasp objects with force, and place her 
hand on the top of her head with facility. On this day, after 
having applied the magnet, she immediately exclaimed that she felt 
the wind for the first time over the right shoulder, and, on exami- 
nation, it was found that sensation, to a certain degree, had returned 
to the right side ; and here you will perceive that the first mani- 
festation of the return of sensibility was denoted by her feeling the 
magnetic influence in the paralysed side. 

I shall not take up your time any longer by detailing cases; it 
will be sufficient to state, that it was used in many other instances 
of a similar kind, and in all with the same result. Each patient 
described the same sensation, with very little variety ; in some, it 
consisted in a feeling of pricking or tingling ; in others, of an aura 
passing over the part. Some stated that they felt a sensation of 
warmth in the part, some time after the magnet had been applied; 
and some, a kind of suction, as if the skin was drawn towards the 
magnet. When it was applied over a very sensible or a blistered 
surface, the patients felt the pricking sensation to amount to pain, 
and the feeling of warmth and suction was proportionally increased, i 
I have also to observe, that it was employed on a set of patients, 
the majority of whom were totally ignorant of its nature and 
effects; and yet it is very remarkable that there was an almost | 
universal accordance in their descriptions of the sensation produced. 
It has been stated, by some writers on the subject, that the sensa- 
tions differ according to the pole of the magnet employed. This 
statement does not accord with our experience ; for in every one of: 
our cases the sensation was the same, whether we made use of one 
pole or the other. As far as our experience goes, it is, I think, fair 
to conclude that a very perceptible influence may be produced on 
the human body by the application of the magnet; it is another 
matter to ascertain how far it may be rendered available as a thera- 
peutic agent. The cases in which I think it might be employed 
with advantage, are cases of nervous and spasmodic affections, and 
muscular rheumatism. That the sensations described by our 



PARAPLEGIA. 



patients had an actual existence, and were not the result of imagi- 
nation, I am firmly convinced. 

Before I leave the subject of paralysis, I wish to draw your 
attention to one more form of the disease, by no means uncommon - ? 
I allude to that in which both the lower extremities are exclusively 
engaged. This is a disease, or s}/mptom, which may arise from a 
great number of causes, and be observed under a variety of circum- 
stances. Generally speaking, however, it will, in almost every, 
instance, be found to depend on some cause which engages the 
spinal marrow, either primarily or secondarily. I believe that this 
paraplegia, as the result of disease of the brain, is never met with 
except in combination with paralysis of the upper extremities. 
General paralysis may be produced by cerebral disease; and in 
describing the various forms of paralysis which depend on disease 
of the brain, this form has been particularly noticed ; but when 
paralysis of the lower extremities alone occurs, it is generally the 
result of some lesion of the spinal marrow, either organic or func- 
tional, below the situation in which the brachial nerves are given 
off. Among the causes by which this paraplegia is produced, the 
following are the principal : inflammations of the membranous 
coverings of the spinal cord, with effusion of lymph or serum ; 
spinal apoplexy, ramollissement from inflammation of its sub- 
stance ; pressure on the cord, by solid tumours from a variety of 
causes ; the bursting of abscesses or aneurismal swellings into the 
vertebral canal, as occurs in some cases of aneurism of the abdo* 
minal aorta. Thus, during the progress of a case of this descrip- 
tion, it has. been observed that the patient suddenly became 
paraplegic, and, on examination after death, a quantity of blood, 
which escaped from the aneurismal tumour, has been found com- 
pressing the spinal marrow. Lastly, recent investigations have 
established the fact that we may have paralysis of the lower 
extremities, and yet, on dissection, ice cannot detect any traces of 
disease in the hones of the vertebral canal, or in the membranes 
or substance of the spinal cord. Hence you see how cautious you 
should be in making the diagnosis, so common among surgeons, of 
caries of the vertebrae, in cases of paralysis of the lower extremities. 
The truth is, that in the present state of medicine on this subject, 
we labour under very great difficulties; the diagnosis of these 
affections is exceedingly obscure ; it is a subject still open to inves- 
tigation, and, I need not remark, that it is one of paramount im- 
portance. 

Paraplegia is one of the most miserable diseases to which the 
human body is liable. It is almost always obstinate and unmanage- 
able, and in the majority of cases incurable. How far the fatality 
of the disease depends upon the want of an accurate diagnosis, and 
i a correct plan of treatment, must be determined by future observa- 
i tions : but it is a fact, that a vast proportion of paraplegic patients 
die, and under the most melancholy circumstances. In many 
I cases, the formation of gangrenous sores on the back and loins is a 

30 



342 



STOKES'S THEORY AND PRACTICE, 



common occurrence. For this there are two reasons : first, the 
vessels of those parts exposed to pressure from position fall into 
that state which Andral terms mechanical hypercemia, the result 
of which is that they are unable to unload themselves, a stasis of 
blood follows, and this leads to mortification of the part ; secondly, 
there is a lesion of innervation. Hence it is, that the great majority 
of patients of this kind die with gangrenous sores on the back and 
loins. They have also most constantly paralysis of the bladder, or 
its sphincter, or both, producing retention of urine, or retention with 
incontinence, or stillicidium urinae. The sphincter ani, too, is 
generally paralysed, and we have a most melancholy and disgust- 
ing source of annoyance. The frequent passing of urine and 
faeces, keeps the unfortunate sufferer in a state at once pitiable and 
loathsome ; and when, in addition to his other calamities, the 
gangrenous sores form, the supervention of low diffused erysipela- 
tous inflammation may prove fatal ; or he may be carried off with 
symptoms of typhus fever, from the absorption of putrid matter. 

While on the subject of paraplegia, I am anxious to lay before 
you a sketch of some important opinions lately put forward by Mr. 
Stanley, of London. In the last number of the Medico-Chirurgical 
Transactions, this gentleman has written a most interesting paper, 
in which he gives the history of several cases of paraplegia, the 
majority of which were supposed to be examples of caries of the 
vertebras, but in which, on dissection, no disease could be dis- 
covered, either in the bones of the vertebral canal, or in the mem- 
branes or substance of the spinal cord. You will ask, were there 
no pathological phenomena in these cases ? There were; but they 
belonged not to the spine or its contents, but to an organ in its 
immediate vicinity — the kidney. From a candid review of Mr. 
Stanley's cases, there appears to be reason to believe that disease 
of the kidneys may produce all those symptoms which have been 
attributed to lesions of the spinal marrow, or caries of the vertebrae. 
In the four first cases, the symptoms given as of caries of the verte- 
brae were present, and the cases treated as such. On dissection, no 
caries, or disease of the cord, could be discovered in any of them, 
but the kidneys were found to be the seat of extensive disease. 
The fifth case was a remarkable one; the patient had been ad- 
mitted for retention of urine, the consequence of severe gonor- 
rhoea, which had been checked by injections. The bladder and 
sphincter ani became paralytic, and he lost the power of the lower 
extremities to a certain degree. He also complained of severe pain 
at the fifth lumbar vertebrae. He distinctly traced the pain from 
the bladder to the left kidney, and then to the right. Paralysis of 
motion, and, nearly, completely of sensation of the lower limbs, 
next supervened, and in about a fortnight he died. On dissection 
the kidneys were found in a state of inflammatory softening, and 
with numerous minute depositions of pus. The bladder was 
inflamed, but the brain and spinal cord were perfectly healthy. In 
the sixth case, a patient, while in progress of cure of a gonorrhoea 



PARAPLEGIA. 



343 



with phymosis, was suddenly seized with paraplegia. The func- 
tions of the brain were unaffected. He had suffered for a day or 
two from pain in the loins. Sixteen hours after this attack, he 
suddenly died. 

From considering the former cases, Mr. Stanley predicted that 
inflammation would be found in the kidneys. A slight turgescence 
of the vessels of the cord, with a little transparent effusion in the 
theca, were found, but the kidneys were in a state of the most 
intense engorgement. In this case, it was remarkable that, from 
the period of the paraplegia, there was an inordinate secretion of 
urine. The seventh case was that of a patient who, for two years, 
had been labouring under pain of the back, increased by pressure, 
and incontinence of urine. On dissection, there was some vascu- 
larity and effusion of the cord, but both the kidneys were almost 
entirely destroyed by disease. In addition to these, Mr. Stanley 
mentions four more cases, which were seen by a friend of his, Mr. 
Hunt, of Dartmouth, which corroborate his opinions. 

Here, then, we may have well-marked paraplegia, without any 
perceptible organic change in the spinal cord, or its investments, 
but presenting distinct traces of disease of the kidneys. This leads 
us to observe the very close connection which exists between the 
kidneys and spinal cord, a connection which has been long recog- 
nised by medical practitioners, but only in a limited point of view ; 
for though they were of opinion that disease of the kidneys, and a 
discharge of ammoniacal urine, were the results of spinal disease, 
they never seem to have reflected that the reverse of this might 
happen. It seems now, however, to be almost completely esta- 
blished, that disease of the kidneys may produce symptoms which 
are referable to disease of the spine ; and Mr. Stanley has the credit 
of having been the first who directed the attention of the profession 
to this circumstance, and his paper must be considered as one of 
the most important, and practically useful, which has appeared for 
a length of time. You should all peruse it carefully. The fact 
that disease of the spine will give rise to affections of the kidney, 
is long known, and has been proved by numerous experiments. 
Thus Oiliviet details the experiments of a German physiologist, M. 
Kreimer, who, by dividing the lower part of the spinal cord in 
animals, made the urine almost immediately ammoniacal You 
will also find, in Dr. Prout's work, that an ammoniacal state of the 
urine may be rapidly brought on by injuries of the back, from falls 
or bruises on the spine. It is, indeed, singular how quickly those 
profound functional lesions of the kidneys supervene on injuries 
of the spine, sometimes appearing in four or five days, sometimes 
sooner. Medical men have hitherto been in the habit of looking at 
this matter only in one point of view ; they know that disease of 
the spine will produce disease of the kidneys, and here they stop; 
but it has been shown that the reverse of this may happen, and 
that renal disease may produce very remarkable lesions in the 
functions of the spine. Of this very curious occurrence, we have 



344 



STOKES'S THEORY AND PRACTICE. 



many analogies in pathology. Thus, for instance, in several cases 
of cerebral disease, but chiefly in hydrocephalus, we have vomiting; 
here we have functional disease of the stomach depending on an 
affection of the brain. Take the reverse of this — observe the deli- 
rium which attends a case of gastro-enteritis — here you have the 
functions of the brain deranged in a most remarkable manner, and 
this produced by sympathy with an inflamed mucous membrane. 
The truth is, that in the spine and kidney, as well as in various 
other parts of.the system, we have two organs which are so closely 
connected by sympathy, that disease of one will bring on serous 
functional lesion of the other. 

Observe, then, the great importance of these inquiries. When 
you meet with a case of paraplegia, you are not at once to conclude 
that it depends on disease of the spine, or caries of the vertebra?. 
You must carefully investigate its history, and ascertain whether 
it may be referred to either of these causes, or whether it may not 
rather depend on disease of the kidneys. That it may depend on 
the latter cause is now established, for the cases are too numerous 
for us to suppose the complication accidental. You will observe 
the importance of making an accurate diagnosis, when you consider 
that this point will most materially influence your treatment. In 
the one case, your treatment will be directed to the bones and car- 
tilages of the spine; in the next, to the spinal cord itself; and, 
lastly, to the kidney, a parenchymatous organ, to which there is a 
great determination of blood. No one will venture to assert that 
the principles of treatment in each of these cases are the same ; and 
the chances are, that, if you do not make a correct diagnosis, you 
will practise improperly and without success. I have now seen a 
number of these cases, but there were only two of this description 
in which I was fortunate enough to obtain a post-mortem examina- 
tion. I cannot say that my dissection exhibited remarkable dis- 
ease of the kidneys (they were large and very vascular), but, from 
the many points of resemblance they bore to Mr. Stanley's cases, I 
was led to conclude, that if they were not examples of actual chro- 
nic disease of the kidney, they were cases of lesion of function in 
the spine, unaccompanied by any organic change to account for the 
symptoms. I shall briefly detail these cases: the first was that of 
an unfortunate man from the country, who was discovered by two 
friends of mine under peculiar circumstances. While on an excur- 
sion, they were requested to visit a poor man who was lying ill at 
a remote farm-house. They heard he had been labouring under a 
dropsical affection for a long time, and had been treated for ascites. 
On arriving at the cottage, they found the man lying in bed, with 
his abdomen very much enlarged ; and, on further investigation, 
discovered that he was quite paralytic of the lower extremities. 
On examining the belly more particularly, they found that the 
swelling was produced, not by ascites, but by an enormously dis- 
tended bladder. He had, also, stillicidium urinse, with paralysis 
of the bladder ; and this having been mistaken, by the medical 



PARAPLEGIA. 



345 



practitioner who attended him, for suppression of urine, he had 
prescribed diuretics, and continued this plan of treatment for some 
weeks, totally overlooking the paralysis of the bladder. As little or 
nothing could be done for him in the remote situation in which he 
lived, it was determined to send him up by easy stages to Dublin, 
and procure him admission at one of the public hospitals. On his 
arrival, he was received at the Meath Hospital ; and, when I visited 
the wards next day, I found that he was quite paralytic of both 
lower extremities, that the bladder was in the state above described, 
and that his health had suffered considerably, and that bed-sores 
had formed on his back, and were increased by his journey. I 
prescribed cupping and blistering, which were productive of some 
slight relief; but in the space of a few days he began to exhibit 
symptoms of low typhus, as if from the absorption of pus, and sank 
rapidly. On examining his body, we could not detect any traces 
of disease in the bones or cartilages of the spine ; neither did the 
cord, or its membranes, present any marks of organic lesion, except 
that towards its lower portion, where it begins to spread out into 
the cauda equina, it was perhaps a little softer than natural. I 
regret very much that I did not note the circumstances of this case 
more fully; but, as far as my recollection of it goes, the general 
features were as I have just mentioned. I had another case, some 
time since, in the Meath Hospital, in which the following circum- 
stances were observed : — The patient, a labouring man, generally 
employed about the quays, was brought into the hospital with 
paraplegia of some standing. The first symptom in his case 
belonged not to the spine, but to the urinary system ; he had had 
an attack of gonorrhoea, for which he had used stimulants and 
balsams ; and, in some weeks after, without any injury to the spine, 
he lost the use of his lower extremities. During his stay in the 
hospital, the urine was intensely ammoniacal. On examining his 
body after death, we could not discover any disease of the bones or 
spinal marrow. A layer of substance, resembling fat, or organized 
lymph, was found lying on the theca of the spinal marrow, but it 
was so very small as to be scarcely sufficient to account for the 
symptoms. The kidneys were pale, flabby, and without any vas- 
cularity, but did not present any marked traces of organic lesion. 

Here, then, were two cases which, before the publication of Mr. 
Stanley's paper, would be considered as examples of organic dis- 
ease of the spinal cord, or its investments ; and yet, on dissection, 
we can find nothing to establish this opinion ; and, in the last one, 
the first affection was of the urinary system. 

Is it possible that afunctional disease of the urinary system may 
produce also a functional disease of the spinal cord? 

With respect to the diagnosis of caries of the spine, I wish to . 
make a few observations. The diagnosis where there is distortion 
of the spine is extremely easy, but this does not hold where the 
caries is accompanied by distortion. Let us inquire. Are there 
any circumstances which would enable us to arrive at the diagno- 

30* 



346 



STOKES'S THEORY AND PRACTICE. 



i 



sis of caries without distortion 1 One symptom, not observed, as far 
as I can see, in paralysis, connected with disease of the kidney, is 
that the patient feels exquisite pain on motion. This is an exceed- 
ingly common symptom in caries of the vertebra?, but I am not 
aware that it occurs in cases where the disease is situated in the 
kidney, or the spinal, cord itself. There is another remarkable cir- 
cumstance : — When the patient attempts to move, he often feels a 
cracking sensation in the affected portion of the spine ; and this 
has not only been observed by the patient himself, but is also per- 
ceptible to his medical attendants. When this occurs, it may, I 
think, be looked upon as a diagnostic symptom. The exquisite 
pain on motion, the tenderness of the spine on pressure, and the 
crackling sensation, these might be sufficient to make the diagnosis 
of caries of the vertebra?, even in cases where there was no distor- 
tion. But if you had a case of paralysis of motion and sensation 
of the lower extremities, and if these symptoms came on without 
any injury of the spine — if there was little or no tenderness on 
pressure — if the patient felt scarcely any pain in turning or moving, 
and if he had at the same time symptoms of disease of the kidney 
or bladder, and ammoniacal urine — under these circumstances the 
great probability would be, that it was not a case of caries of the 
vertebrae, or original disease of the spinal cord, or its investments, 
but a lesion of function of the spine, connected with organic or 
functional derangement of the kidneys. It must be acknowledged, 
however, that the diagnosis of this affection is rather obscure. The 
circumstances which I have just mentioned, might enable you to 
get rid of the opinion that it was caries of the vertebras or organic 
disease of the spinal cord, and that it was probably such a case as 
Mr. Stanley has described ; and if you could arrive at this diag- 
nosis at an early period of the case, it would be a matter of great 
importance. By doing this, you would then be aware that you had 
to deal with an inflammatory affection of a highly vascular organ ; 
you would not be led away from the real state of the case, or waste 
time in treatment calculated to stimulate the spine, or remove dis- 
ease of the vertebra?. Your plan would be simple, and your treat- 
ment defined, and all your efforts would be directed towards 
removing the disease of the kidneys. Y"ou will easily perceive that ! 
diagnosis is here of vast importance ; unfortunately, it is still 
involved in obscurity. 

The prognosis of cases of paraplegia, when once complete para- j 
lysis is established, should be always unfavourable. The fact of 
paralysis occurring, is sufficient in itself to prove the existence of 
extensive disease in most cases, There may be, however, some 
cases susceptible of cure, and this particularly occurs in young 
females, in whom a perfect cure has been frequently accomplished > 
by the use of stimulant embrocations to the loins. I have seen one 
case of this kind, in which the patient was paraplegic for a year 
and a half, cured by the application of hot oil of turpentine over 
the lower part of the spine. Simple as the treatment may appear 



I 



[PARAPLEGIA.] 



347 



in this case, its success was rapid and complete. Mr. Crampton 
has mentioned to me the particulars of another case, in which the 
patient's limbs were quite rigid, and could not be moved without 
great difficulty; in this case, complete relief was obtained by 
applying Pearson's liniment over the lower part of the spine. This 
liniment produced powerful counter-irritation, and an eruption of 
bullae over the body, which were speedily followed by relief. The 
patient is now in the enjoyment of perfect health ; and since the 
period of her cure, which is now better than six years ago, has had 
no return of the disease. 

[In confirmation of the occasional origin of paraplegia from 
visceral disease, as stated in the preceding lecture, the following 
facts are added : Dr. Graves {Clinical Lectures) relates the case 
of a man who had, consequent on exposure to cold, wet and 
fatigue, become affected with pain and weakness of the lower 
extremities. During the time his legs and back were getting weak, 
he was obliged to pass water about three times in an hour, which 
he did with pain and tenesmus. At the time of his admission into 
the hospital, he appeared somewhat broken down in his general 
health ; he was pale, emaciated, and laboured under derangement of 
his digestive organs. He suffered from occasional chills, succeeded 
by heats and sweating, w r hich occurred at irregular periods ; he, 
also, laboured under micturition, dysuria, and the stream of urine 
was much diminished. The pain in his back was very severe, 
and he lost the use of his limbs, but not completely, for he could 
! support himself, and even walk a little, with the aid of tw r o sticks. 
His treatment w 7 as as follows : First, cupping over the loins, 
then moxae in the same situation; attention to his digestive organs; 
diluents and opiates for the urethral symptoms. On the tenth day 
after his admission, a very close stricture was found to exist in the 
membranous portion of the urethra. A small cat-gut bougie of 
double length w r as introduced, so that one-half of it projected from 
the meatus ; over this was slided a small gum-elastic catheter of 
ordinary length, and open at each end, until it traversed the stric- 
ture, and reached the bladder ; the cat-gut bougie w r as then with- 
drawn, and the gum-elastic catheter secured. A little constitutional 
disturbance followed, but soon subsided, and in a few days gum- 
elastic catheters of a much increased size were introduced with 
facility. 

" A very remarkable amendment took place in his back and lower 
extremities, in a very few days after the first introduction of the 
instrument ; in fact it was almost sudden. Warm baths, friction 
to his limbs, &c, completed his cure." He was discharged on the 
! 25th February (admission on the 16th January), at which time 
I the pow T er of his lower limbs was perfectly restored, and the symp- 
i toms affecting the urinary system had disappeared. This case was 
j reported to Dr. Graves by Dr. Hutton, under whose care the patient 
| was placed. It proves, as Dr. G. remarks, '* that urethral irritation 



318 



STOKES'S THEORY AND PRACTICE. 



may; as well as inflammation of the kidneys, give rise to para- 
plegia." This man had gonorrhea, followed by gleet from which 
he recovered five years before his attack of paraplegia. 

Several examples have been witnessed by Dr. Graves of more 
or less complete loss of power of the lower extremities, supervening 
on inflammation of the gastro-intestinal mucous surface. 

Paraplegia sometimes occurs during the course of a fever. 
Here, as Dr. Graves remarks, the other sufferings of the patient, 
and his general debility attract our notice so exclusively, that the 
paralysis entirely escapes notice until convalescence is established — 
until, in fact, the patient wishes to support himself on his legs. 
He then finds, much to his surprise, that his limbs yield under him. 
This appears to him the more extraordinary on account of his 
having recovered a good deal of strength in his upper extremities. 
Mr. Carmichael has seen several cases of paraplegia following the 
remittent gastric fever of children, totally unconnected with spinal 
disease. Such an occurrence is most usual in children of a scro- 
fulous temperament, and is seldom, Dr. Graves thinks, remedied 
either by time or medicine. A remarkable exception to this unfavour- 
able prognosis has recently occurred in a young patient of mine, 
aged nine years. This boy, who is of a scrofulous habit, has had 
bad health from infancy ; at first bowel complaints, long and ex- 
hausting, then bronchial disease, also protracted and harassing, and 
enlarged tonsils. To these succeeded a posterior curvature of the 
first dorsal vertebra ; and about ten months ago an inability to walk 
well and a leaning to one side. He was subjected at this time to 
regular treatment — a horizontal posture, counter-irritation along the 
spine, and took the hydriodate of iron and laxatives internally. Ere 
long he lost the use of his lower limbs entirely, and continued thus 
helpless throughout the winter — with, at times, a partial stoppage of 
urine, and sometimes involuntary discharges of faeces, and some- 
times constipation. During this period a scrofulous tumour appeared 
on the left side of his neck, which eventually suppurated, and has 
continued to discharge up to the present date (June). Another but 
smaller tumour on the opposite side soon reached the suppurative 
stage, some time after the other was emptied, and has left a small 
opening, from which oozes out a fluid. In the early part of the 
spring this boy recovered the use of his limbs so as to be able to- 
perform the movements of flexion and extension in bed or on a 
sofa ; and since then,, and for about two months past, is able to 
stand with the aid of some support. That of which he chiefly 
makes use is the spine-cart, in which he now walks with tolerable 
ease. In addition to the other symptoms the patient had, during 
much of the winter, a troublesome cough and hectic with night 
sweats. His chief and almost sole medicine, which he has taken 
for some months past, is the sulphate of quinine, and occasionally 
an alkaline mixture with a little laudanum for his cough, which is 
now much better, and the hectic has in a great measure disappeared. 
After the cessation of the use of irritating ointments, and of blisters 



[PARAPLEGIA.] 



349 



applied to the spine, the external treatment for a long time past, and 
anterior to the restoration of muscular power of the lower limbs, 
has been friction with a flannel, and sometimes the hand, and rub- 
bing in of the common volatile or soap liniment, on the spine and 
lower limbs. 

Without adopting in all their entireness the opinions of Dr, 
Graves, we ought to imitate his practice more frequently than we 
do, by employing appropriate measures for the relief of the pain in 
the back, which is so common in the beginning of fever. " When 
headache is the prominent feature of the first stage of fever, how 
few will omit bleeding, leeching, cupping, cold or hot applications, 
&c. When, on the contrary, the lumbar spinal marrow is the seat 
of the congestion, how T generally do practitioners neglect the appli- 
cation of topical bleeding and other appropriate remedies. Were 

| such neglect of less frequent occurrence, it is probable that para- 

| plegia after fever would not probably be met with." 

Partial paralysis, as that of a limb, sometimes ensues on irritation 
transmitted from some part of the surface. Thus, in a case of ery- 

| sipelas of the calf and inside of the right leg, described by Dr. 

I Graves, which yielded to appropriate treatment, there was for some 

I time a loss of power of motion in the affected limb. Sometimes 
the reverse happens, and pressure, as of the head on the arm in 
sleeping, has been followed by a palsy of this limb of several years* 
duration ; and in another case a fall on the left hip and trochanter 
produced a permanently paralytic state of the left lower extremity. 

I No injury of the spine could be detected, and there was no numb- 
ness, pain, or formication, in the affected limb. 

In the views of treatment of paraplegia supervening on visceral 
jdisease laid down by Dr. Graves, I fully coincide. He says that he 
has never seen any benefit derived from applications to the spine, and 
that the application of blisters or issues over the back or loins does 
not appear to be productive of the least good effect. He is in the 
habit of applying his local remedies to the legs and thighs, selecting 
those parts in which the greatest sensibility exists. Confirmatory 
of the proprietjr of this course is a circumstance which occurred in 
the case of my little patient whose case I have already described. 
At a time when he was completely paraplegic and unable to move 

I either of his lower limbs except by grasping one or other of them 
with his hands, and dragging it up a little from the bed, moderate 
friction of the skin of the lower part of the leg would often be fol- 
lowed by a regular but involuntary contraction of the muscles both 
of the leg and thigh, so that the knee was partially bent, and the 
thigh partially flexed on the pelvis. This fact encouraged me to 

j urge a continuance of the frictions, which had been before regularly 
practised, of the feet and legs. 

Dr. Graves generally keeps up a succession of blisters along the 
inside of the legs, and over the anterior and inner part of the thighs, 
aided by the use of liniments of a stimulating kind applied to the cuta- 
neous surface of these parts. The two internal remedies on which 
he relies most, are strychnia and sulphur ; the former of these he 



S50 STOKES'S THEORY AND PRACTICE. 



continues until some sensible effect on the system is produced, when 
he omits its farther use and has recourse to the exhibition of sulphur 
in the form of an electuary. Much, also, will be accomplished by 
the external use of sulphur, and of course of sulphur water, and 
hence cases of paraplegia have been materially benefited by the 
external use, combined with drinking them, of the waters of Harro- 
gate, Bareges, &c, and of our own White Sulphur in Virginia. — B.] 



LECTURE XXXII r. 

Sudden paralysis from abscess of the brain — Curious case of paralysis without effusion 
— Previous symptoms of — Demonstration of the cellular tissue of the brain — Com- 
pressibility of the brain — Inaccuracy of the opinions of Drs. Abercrombie and Clut- 
terbuck — Pathological states — Arachnitis without delirium — Traumatic apoplexy — 
Case of paralysis of the portio dura — Peculiar appearance of the affected side of the 
face — Use of the electro-puncturation — Bad effects from — Mechanical support of 
paralysed parts — Neuroses, active and passive — General pathology of — Principles of 
diagnosis — Case of neuralgic liver — Neurosis from moral causes. 

Before I leave the subject of organic affections of the brain, I 
wish to exhibit a few preparations illustrative of some of the prin- | 
cipal diseases dwelt on in the preceding lectures. You will recollect 
that, in a former lecture, I alluded particularly to the question, 
how far we are able to judge of the existence of apoplectic effu- 
sion by the sudden occurrence of an attack of paralysis. I endea- 
voured then to impress upon you that we may have sudden paralysis 
from other causes, as well as apoplectic effusion, and stated that 
there were numerous cases of sudden paralysis, with disorganization 
of the brain, on record, depending, not on apoplectic effusion, but 
on circumscribed abscess of the brain; and that, consequently, the 
diagnosis of apoplectic effusion from suddenness of attack was j 
only valuable when it came on unpreceded by symptoms of local j 
disease of the brain. I alluded to a remarkable case of aneurism j 
of the arteria innominata, in which the patient, soon after the date \ 
of his admission into the hospital, had become suddenly hemiplegic. i 
This was a case in which one would be led to expect an effusion \ 
of blood into the brain, as the circulation of the head was evidently ji 
impeded by the pressure of the aneurismal tumour on the great \ 
veins, and as there was a remarkable distension of the jugular and \ 
other superficial veins. Of the existence of the aneurism there ■ 
was not the slightest doubt ; the tumour could be felt pulsating u 
below and above the clavicle on the right side, compressing the >i 
trachea, so as to cause stridulous breathing, and producing a vari- | 
cose state of the veins of the neck by its pressure. We accordingly j 
made the diagnosis of aneurism of the arch of the aorta, or of the 1 
arteria innominata. In this case two circumstances — the sudden I 
paralysis of one side, and the obstruction to the circulation of the j 
neck and head — would, as I have said before, lead to the supposition m 
of an apoplectic effusion. On dissection, however, the paralysis 
was found to depend, not on this circumstance, but on the existence ; 1 



PARALYSIS. 



3. r )l 



of a circumscribed abscess in the anterior part of the opposite hemi- 
sphere of the brain. I have the pleasure of exhibiting to you to-day 
this interesting and important preparation. It is too large to send 
round, but you can all inspect it after lecture. Here is the aorta 
from its commencement at the left ventricle — here is the enormous 
aneurism of the arteria innominata compressing the trachea — so 
that it has not only pushed it far to the left side, but has flattened it 
in such a manner as to produce a curious alteration in the appear- 
ance of its musculo-membranous structure. The terminations of 
the rings of the trachea are brought close together, and the muscu- 
lar parts are folded in between them. There is another circum- 
stance here deserving of your notice : the right carotid, you see, is 
obliterated ; it is interesting to connect this fact with the absence of 
true apoplectic effusion. The case altogether is a curious one, and 
| presents two remarkable circumstances — great mechanical obstruc- 
I tion to the venous circulation of the head, and sudden paralysis 
; without effusion. It is, however, to be remarked, that in this case, 
though the paralysis was sudden and unexpected, it. was preceded 
i by some symptoms of local disease of the brain. The patient had 
i pain in the head and limbs of one side, accompanied by a sense of 
formication. These symptoms were remarked some days before 
the attack of paralysis, but their importance was not at that time 
i thoroughly estimated, in consequence of a greater share of atten- 
| tion being directed to the aneurismal disease. 

In this bottle, you have a specimen of that species of ramollisse- 
( ment which supervenes on local inflammation of the brain. We 
have every reason, I think, to believe that when this disease occurs 
in the young, or in the adult, it is the result of an active inflam- 
matory process ; and that softening of the brain has in it nothing 
more specific or peculiar than softening of the liver or lungs from 
acute inflammation. Here, you see, is the disease — an irregular 
cavity filled with broken up cerebral matter, somewhat resembling 
cream in appearance and consistence. I may remark here, that it 
is in cases of this description that we are able to demonstrate the 
existence of the cellular membrane of the brain. This cellular 
membrane is extremely fine and delicate — so much so, indeed, that 
some anatomists of high authority have asserted that the brain 
possessed no interstitial cellular tissue. This preparation, how- 
ever, gives a proof of the great light which pathology frequently 
throws on obscure points of anatomy and physiology; for, though 
the interstitial cellular tissue cannot be seen in the sound brain, we 
are able, in the preparation before us, to demonstrate its existence 
with certainty. It is, however, to be observed, that it is only 
j in recent cases of ramollissement that this phenomenon can be 
! examined with advantage ; for, in those of long standing, the cellular 
I membrane shares in the general destruction, more or less, and gives 
| way. But if you get a case where the softening is recent, and 
1 then take the softened portion of the brain and expose it to the 
dropping of a filter, you will find that the soft cerebral matter will 



352 



STOKES'S THEORY AND PRACTICE. 



be gradually washed away, leaving behind it a delicate tissue ; and 
in this way you can prove the existence of cellular membrane in 
the substance of the brain, like that of other parenchymatous 
organs. 

Here is a specimen of apoplectic effusion : see how extensively 
the substance of the brain has been torn ; the cavity formed in this 
way is, you will perceive, filled up with a large clot. Now, there 
is one consideration which strikes us at once, in looking at an effu- 
sion of this kind into the substance of the brain, whatever may be 
its situation or extent — and this is, that the brain must he a very 
compressible organ. Here we see the brain torn, a cavity of large 
size formed, and this completely filled with blood. Now, it is 
obvious that the rest of the brain must give way, in order to give 
room for the formation of this cavity. If, then, it be true that the 
brain is compressible, so far as to admit of the formation of a large 
cavity, it necessarily follows that, contrary to the opinion of Drs. 
Abercrombie and Clutterbuck, the quantity^of blood in the brain 
may vary, and be greater atone time than another. These authors 
think that the quantity of blood circulating in the brain never 
varies, but here, you will perceive, we have a remarkable cavity ; 
and it is plain that the rest of the brain must have yielded before 
it could be formed ; and it follows, as a natural inference, that the 
brain must be compressible, and that, consequently, the quantity 
of blood contained may vary at different times. It maybe argued 
against this, that the illustrative proof in this case is derived from 
a pathological condition, and that, under such circumstances, the 
brain has room for the formation of a cavity, by the emptying of 
some of its vessels. Here, it is urged, is a cavity, but the empty- 
ing of the vessels of the brain compensate for it ; thus room is 
found, and there is no increase in the quantity of blood circulating 
in the brain. This, however, I look upon as a mere petitlo prin- 
cipii ; nor have we any reason to think, that, in a case of apo- 
plectic effusion, there is any corresponding emptying of the vessels, 
for dissection almost always shows a surcharged state of all the 
vessels. The result, then, in my opinion, is, that the brain is com- 
pressible, and may admit a larger quantity of blood at one time 
than it does at another. On this subject I advise you to consult 
Dr. Mackintosh's work on the Practice of Physic, and also the 
review of Dr. Clutterbuck's Essay on Apoplexy, in the London 
Cyclopaedia of Practical Medicine, as given in the Dublin Medical 
Journal, Vol. II. 

Here is another specimen. You see the brain, with a small clot 
in its substance about the size of a hazelnut. The patient in this 
case did not die suddenly; the clot has nearly lost the appearance 
of blood, and the processes of absorption were going on. I have 
got here another preparation illustrative of this effect on one of 
those effusions. I told you, in a former lecture, that in these cases 
one of two things occurred ; either the clot was wholly absorbed, 
and a serous cyst left in its place, or it was not absorbed, and be- 



PARALYSIS. 



353 



came to a certain extent organized; and that this might be the 
history of many of the anomalous tumours we meet with in the 
brain. Here is a clot, fully as large as a walnut, in which no 
absorption has taken place, and you perceive it has been converted 
into a mass of a dense solid texture. You can easily conceive 
that the brain, having a clot of such a texture in its substance, 
could not easily recover its functions, and that the paralysis would 
be persistent. Here is another large apoplectic effusion, in which 
a certain degree of change has been produced ; the clot, you see, 
has lost a good deal of its colour, and is not so red as in its recent 
state. Here is an excellent specimen of circumscribed abscess of 
the brain in the centre of one of the hemispheres. In this you 
can, to a certain degree, demonstrate the cellular membrane of the 
substance of the brain ; but, if the preparation had been manipu- 
lated in the way I have mentioned, I have no doubt that it would 
exhibit it much better — that is, provided the abscess was of recent 
occurrence. If it should happen to be of long standing, the 
cellular membrane generally gives way, and you have nothing but 
a cavity filled with softened matter. This large preparation exhi- 
bits an enormous effusion on the surface of one of the hemispheres 
of the brain ; it was the result of an injury of the head, and was 
accompanied by paralysis of the opposite side. It furnishes an 
example of what has been termed traumatic apoplexy. The other 
preparations on the table do not apply so immediately to the illus- 
tration of apoplectic effusions, and I shall pass them over. 

Here is a preparation which I would draw your attention to, as 
it belongs to a very remarkable case. I mentioned before, that, in 
certain cases of arachnitis, where the disease was chiefly situated 
at the base of the brain, it had been observed that there was seldom 
delirium. In this case the patient complained of pain along the 
base of the skull, which occasionally remitted and then returned 
with violence, and it was at first supposed to be neuralgic. He 
continued in this state for some time, having a recurrence of vio- 
lent pain in the ear, temporal and mastoid regions, which lasted 
for several days ; when, all of a sudden, without any preceding 
delirium, he became comatose, and died shortly afterwards. On 
dissection, the arachnoid covering of the brain was found to be in a 
state of extensive disease over the inferior surface of the anterior 
lobe, and towards the posterior part, of the base of the brain. Here 
we had a case of extensive and fatal arachnitis, with total absence 
of delirium. 

When speaking of the employment of galvano-puncturation in 
the local treatment of paralytic affections, I stated that the case in 
which the most decided benefit was observed occurred in paralysis 
of one side of the face, apparently unconnected with actual disease 
of the brain, and of a local nature. This is in accordance with 
what has been observed with respect to the efficacy of all local 
measures employed in the treatment of paralysis; and, accordingly, 
the more the affection is purely of the nerves of the part, the more 

31 



354 



STOKES'S THEORY AND PRACTICE. 



satisfactory should be the results of galvanism. I shall read for 
you the notes of this case, and I am happy to have it in my power 
to lay before you two excellent drawings of the patient's appear- 
ance before and after the use of the galvanic battery, from the pencil 
of my friend, Mr. Berthon. 

" A bricklayer, named T. Hogan, got an attack of erysipelas of 
one side of the face, accompanied by a feeling of pain and stiffness 
between the angle of the jaw and mastoid process of the right side. 
This was followed by an attack of paralysis of the right side of the 
face, and he presented himself for admission at the Meath Hos- 
pital in the following state. The features at the right side of the 
face are blank, unmeaning, and motionless, while those of the left 
side retain their natural cast, except that their lines are more 
strongly marked, and the angle of the mouth is drawn upwards and 
towards the left side to a considerable extent. The skin of the 
right side of the forehead is smooth, that of the left furrowed and 
puckered. The lids of the right eye are half closed, and he has 
not the power of moving the upper one. When desired to close 
his eyelids, the eyeball rolls upwards, and the transparent cornea 
is carried behind the curtain of the upper lid. By this movement 
the patient excluded all objects, and was under the impression that 
he had shut his eye. The lower lid hangs down, and is partly 
everted, exposing the conjunctiva, and allowing the tears to trickle 
down the cheek. When he breathes, the right cheek is puffed out ; 
it becomes still more distended by an attempt at blowing; and, 
when attempting to drink, a quantity of the fluid escapes at the 
right angle of the mouth. On being requested to draw the right 
angle of the mouth towards the corresponding ear, not the slightest 
movement was made, except by the muscles of the opposite side. 
In masticating his food, the morsel gets between the cheek and gum 
of the right side, and he is obliged to put in his finger to dislodge 
it. Sensation on the paralysed side is unimpaired, and there is no 
deafness, alteration of taste, or loss of vision. With respect to the 
muscular functions of the tongue, they appear to have suffered no 
injury, and he can direct it with facility to either side. Here was 
a fact to show that the paralysis of the face in this instance had no 
connection with cerebral disease. In the majority of cases of 
paralysis of one side of the face, from diseases of the brain, there 
is lesion of motion of the tongue, but here it was in its natural con- 
dition. There is a slight degree of thickness of speech, which can 
be remedied by supporting the paralysed cheek with the palm of 
his hand. He complains of a feeling of stiffness in the jaws, and 
cannot open his mouth more than what would be capable of admit- 
ing a teaspoon. He has had some tenderness over the mastoid 
process. He can press hard substances with his teeth ; and the 
temporal, pterygoid, and masseter muscles seem to be as strong on 
the paralyzed as they are on the sound side. He can move the 
lower jaw so as to incline the symphysis to either side, but more to 
the left than to the right. His general health is good, and his 



■ 



PARALYSIS. 



355 



bowels regular." I shall hand round the drawings of this case for 
your inspection. You will observe the peculiar appearance of the 
left side of the face, with the mouth drawn upwards, and the skin 
of the nose and forehead thrown into deep wrinkles. There can 
be no doubt that the exciting cause of the paralysis in this instance 
was connected with the erysipelas of the face. He had no symp- 
toms of any cerebral affection, and the paralysis was limited to 
those muscles which are supplied by the seventh pair of nerves. 
The tongue was quite unimpaired in its motions, and there was no 
lesion of taste, hearing or smell. It was, in fact, a case of purely 
local paralysis, and bore a decided analogy to those cases which 
have been so accurately described by Sir Charles Bell as depending 
on an affection of the seventh pair of nerves. 

The treatment of this case was in accordance with the views 
already detailed ; the diagnosis was paralysis of the seventh nerve, 
and the treatment founded on this diagnosis proved eminently suc- 
cessful. The first thing done was to apply a few leeches to the 
ramus of the jaw ; we then used stimulating applications, and he 
used for some time the liniment, camphorse compos, with extract of 
belladonna. After this he was put on strychnine, which did him 
some good ; but there was so great a susceptibility of its action, 
that we were ultimately obliged to give it up. The last remedy 
employed was electro-puncturation, under the use of which he 
improved rapidly. On the 5th of March the galvanic battery was 
first applied ; the needles at that time were inserted — one in front 
of the ear, and the other near the symphysis of the chin ; subse- 
quently they were inserted in various parts of the right side of the 
face, following the different branches of the portio dura. On the 
first application of the galvanic influence, he had spasmodic twitches 
of the paralysed muscles, and soon afterwards he began to complain 
of a burning sensation in the cheek and pain in the head. Here, it 
would appear that headache was the result of the proximity of the 
stimulus to the brain. On the 11th, the symptoms were nearly 
the same, and his general health continued to improve. On the 
1 5th, the application of the galvanic influence was followed by 
severe headache, which lasted for half an hour. On the 19th, his 
appearance was much improved, and the galvanic battery was not 
used. On the 20th, it was again applied, and in an hour afterwards 
he had rigors and slight headache. On the 21st, after using the 
battery, he had rigors again, followed by headache and a pricking 
sensation in the cheek. On the 24th, he left the hospital in a re- 
markably improved state. Expression had returned to the side of 
the face which had been previously unmeaning and blank ; the 
furrows which had deformed the opposite side were removed, the 
| thickness of speech diminished, and the paralysis of the buccinator 
; had been so far relieved that he was able to manage soft articles of 
j food without being under the necessity of removing them from 
between the cheek and gum with his finger. In this case we em- 
ployed an adjuvant which should be mentioned ; we supported the 
paralysed parts for some days with strips of adhesive plaster, to 



356 



STOKES'S THEORY AND PRACTICE. 



restore the position of the mouth. This was done on the principle 
recommended by Dr. Pemberton, in the treatment of paralysis of 
the fore-arm and hand from painters' colic. By applying strips of 
plaster near the angle of the mouth, and drawing them back and 
fixing them behind the ear, we endeavoured to counteract the pre- 
ponderating antagonism of the muscles of the opposite side. For 
the report of this case, I am indebted to Mr. K. Ellison, of Liver- 
pool, who had the charge of the patient in the Meath Hospital, a 
gentleman whose talents are only equalled by his untiring zeal in 
the study of pathological medicine. 

The foregoing case is interesting in two points of view ; first, as 
to its peculiar phenomena, and. in the next place, as to the success 
of local treatment. It also shows that w r e may go too far with 
electro-puncturation, particularly when it is applied to parts which 
are situated close to the brain. You recollect that, in Mr. Hamil- 
ton's case of amaurosis, three pairs of plates were capable of pro- 
ducing a degree of stunning and insensibility which lasted for some 
time. In this case the rigors and headache showed that the gal- 
vanic fluid had a powerful effect, and would lead us to be cautious 
in using it too freely, where the parts to which it is to be applied are 
situated in the vicinity of the brain. 

We have now taken a very brief sketch of some of the most 
important organic affections of the brain : but, in the study of dis- 
ease, we constantly meet with a vast number of cases presenting 
the most extraordinary nervous phenomena, and yet we are unable 
to discover, by the closest pathological investigation, any appre- 
ciable lesion of the nerves, spinal cord, or brain. These are the 
class of diseases which have received the name of neuroses. We 
find, in most of these affections, a remarkable alteration in the 
nervous functions without any perceptible or constant organic 
change; we find, too, that this alteration maybe connected with 
an exaltation or a depression of the nervous power; and from this 
circumstance results the division of neurotic affections into active 
and passive — active where the nervous power is elevated, and 
passive where it is depressed. The spasms which accompany an 
attack of flatulent colic, the exquisite pain of tic douloureux, and 
the wild intellectual exaltation of mania, are examples of active 
neuroses. A patient in the second stage of painters' colic will have 
paralysis of motion and sensation of the fore-arm ; there is here an 
obliteration, or at least a diminution, of the nervous function, and the 
disease furnishes us with an example of passive neurosis. 

Of these two classes the active are certainly the most interesting 
in many points of view. We find, under the class of active neu- 
roses, some of the most extraordinary diseases to which the human 
body is subject ; all the different varieties of spasmodic affections — 
chorea, epilepsy, tetanus, hydrophobia, tic douloureux, hysteria, 
and a host of others, come under this denomination. It is a melancholy 
reflection then, that, in the present state of medical science, we are 
not only ignorant of the ultimate cause of most of these diseases, 
but even of the causes of the variation in their phenomena. 



NEUROSIS. 



357 



You will recollect that, in a former lecture, I threw out a con- 
jecture on this point, and stated that there might be changes of an 
organic nature connected with these affections, not appreciable by 
any mode of investigation at present known: and that it was pos- 
sible that there might be a change in the nervous substance, quite 
independent of any addition or subtraction from the component sum 
of their organic molecules, but in all probability connected with a 
new and different arrangement of these molecules. The analogy in 
this instance is drawn from chemistry, and, I think, may obtain 
here, as well as in the phenomena of Isomerism in inorganic bodies. 
You are aware that many bodies, which seem to present exactly 
the same component elements,- are found to be extremely different 
in their properties, and that this difference has been accounted for 
by supposing that it depends, not on any addition or subtraction of 
the component molecules, but on some difference in their mode of 
arrangement. Now, if this happens in the case of inorganic bodies, 
there is no reason why it might not also occur in organic sub- 
stances ; and, if so, we may understand why a state of the brain 
and nerves, which appears to us to be normal and healthy, may still 
be essentially different, and give rise to the most extraordinary 
phenomena. 

I shall not detain you with any further remarks on this subject — 
it is too obscure to be treated of in a course of lectures on the prac- 
tice of medicine ; let us turn to the consideration of the actual state 
of our knowledge on the subject of nervous affections. In the first 
place, we know that in the neuroses there is no change discoverable 
which could account for the symptoms ; and that, if w T e examine 
the nervous centres to explain the phenomena of paralysis in one 
instance, of epilepsy in another, of mania in a third, of hydrophobia 
in a fourth, and so on, the most minute investigations will not, in 
the majority of cases, point out any deviation from the healthy con- 
dition sufficient to account for the phenomena. We find, too, not 
.only that the state of the brain does not present any constant dif- 
ference in the foregoing diseases, but also that there is often not the 
slightest trace of anything like inflammatory action — a fact borne 
out by the most extensive experience — and showing that treatment 
which would relieve ordinary cases of inflammation of the brain 
will here prove useless. There is one curious circumstance con- 
nected with these neuroses which you should be aware of, and this 
is — where the patient, after suffering from a nervous affection for a 
long time, d'es, you may find organic disease on dissection; but 
here there appears reason to believe that organic changes of the 
cerebro-spinal centres, taken in the proper acceptation of the term, 
are, in reality, the result of some state of these centres which existed 
j previous to the attach, and was the cause of cdl the nervous phe- 
I nomena. We arrive at this conclusion for two reasons: first, 
: because such changes are by no means constant ; and secondly, 
I because they are only found where disease has been a long time in 
existence. 



358 



STOKES'S THEORY AND PRACTICE. 



Nervous phenomena, independent of organic lesion, have been 
divided into two classes — namely, neuroses of the nerves of animal, 
and neuroses of the nerves of organic, life. With respect to animal 
life, or the life of relation, we may have its neurotic affections of 
an active or passive kind ; we may have pains, spasms, and exalta- 
tion of intellect, under the active form : under the passive, we may 
have extinction of muscular motion, sense, and the intellectual 
functions — the life of the individual being still preserved. With 
respect to the system of organic life, it would appear that, if we are 
to speak in general terms, we must admit that there is no passive 
paralysis of the nerves of organic life, they being liable to the active 
neuroses alone — for a passive neurosis of the ganglionic system 
implies death ; yet, to a certain degree, as I have formerly stated, 
such a passive neurosis might exist in the visceral nerves. But we 
may have the phenomena of the active neuroses in all parts of the 
body, whether muscular or visceral. It is a singular fact, that in 
some visceral diseases we have signs of high exaltation of the 
nervous functions of the parts, in others not. Why is this the case ? 
I think it must chiefly depend on the mode or degree of excitability 
of the brain, which is very different in different persons. There is 
no known organic difference between the gastritis with delirium, 
and the gastritis of a man in his senses : nor is there any difference 
between the hepatitis of a man of bilious, and the hepatitis of a man 
of nervous temperament : and we have, in order to explain the va- 
riety of the symptoms, to refer to some original conformation or 
mode of excitability of the sentient centre. Whether this difference 
depends on an original organization, or on excess or deficiency of 
parts, or on phenomena similar to those of Isomerism, we know not. 
As the result of experience, we are forced to admit that these phe- 
nomena have no necessary connection with the inflammation of the 
suffering part, or of the brain ; and this proposition applies to the 
great majority of cases which are called nervous. Experience has 
also proved the truth of this from the results of treatment — for it 
has proved that the most successful treatment is that which is by no 
means calculated to remove inflammation (in its ordinary accepta- 
tion), either from the brain or from the suffering parts. The 
progress and duration of these cases, also, tend to prove the same 
thing ; for, if we were to measure the degree of inflammation 
by the amount of pain suffered, it would be of an intense character 
and rapid fatality ; and yet we find that, notwithstanding the 
violence of the symptoms, these diseases may go on for a number 
of years. 

It is quite plain, then, that the pathological condition of a neu- 
rosis is not inflammation. Now, one of the most common mistakes 
in the practice of medicine is the taking these neuroses for cases of 
local inflammation ; and this, I need not tell you, is frequently 
productive of most distressing consequences. There is one -point 
connected with those violent nervous attacks which leads to a per- 
sistence in this error; and this is, that local antiphlogistic treatment 



NEUROSIS. 



359 



gives temporary relief, although, in the majority of instances, this 
is of very brief duration, and the pain and other symptoms return, 
leaving the patient worse than he was before. From the fact of 
temporary alleviation following depleting means, however, the idea 
of inflammation gets into the practitioner's mind, and the patient 
himself is favourably disposed to that plan of treatment from which 
he has obtained a momentary relief. The consequence is, that a 
system of general and local depletion is continued, until a period 
arrives when the nervous excitability gets to an alarming height. 
Now, is there any circumstance, or class of circumstances, which 
would lead to the diagnosis of these affections ? I feel certain that 
in many instances this must be a matter of some difficulty. By a 
careful study of the symptoms, however, you will, in most cases, 
be able to arrive at the truth. The first thing to which I would 
direct your attention, in studying the diagnosis of such cases, is 
the extreme violence of the pain. Now, this intensity of suffering 
seldom occurs in cases of inflammation ; and it is a curious fact, 
that the most painful diseases are the non-inflammatory. The 
agonies of a patient labouring under neuralgia of the liver, or of 
the left side, or under tic douloureux, are dreadful ; the pain is far 
more intense than in any case of inflammation : and yet, notwith- 
standing all this excess and persistence of suffering, we do not see 
that the duration of life is necessarily curtailed. In the next place, 
you will observe that these attacks frequently recur, and that, though 
long continued and violent, they do not affect the patient's life, 
which would not be the case if they were connected with inflam- 
matory action. If you add to all these circumstances a knowledge 
of the constitution, temperament, and habits of the patient, you will 
have still clearer notions. But there are other circumstances besides 
these to guide you. In the majority of cases, you will find that all 
the local and general signs of inflammation, with the exception of 
pain, are absent. A female, labouring under neuralgia of the liver, 
will have frightful pains in the right hypochondrium, and yet, if 
you examine her, you find that she has little or no hepatic derange- 
ment, no tumour in the region of the liver, no derangement of the 
digestive system, and (though the disease has lasted for years) no 
dropsy, and in many cases no appearance of jaundice. She has 
no fever, thirst, or loss of appetite ; her tongue is clean, her com- 
plexion clear, her stools natural, and her pulse soft. All these cir- 
cumstances tend to show that, however violent the pain may be, it 
has no connection with inflammation. You will be assisted further 
in your diagnosis, by finding that the access and cessation of these 
attacks are equally sudden and unexpected — two characters which 
do not belong to organic diseases. The quick supervention and 
sudden cessation of these diseases should lead you to suspect that 
they were not inflammatory. It may happen, in cases of inflam- 
mation, that pain may come on suddenly, and as rapidly cease ; 
but, though it may come and go in a brief space of time, still you 
will find that lesion of function or structure remains. Thus, in a 



! 



360 STOKES'S THEORY AND PRACTICE. 

case of pleuropneumonia, the pain of the side may cease suddenly 
under treatment ; but the stethoscope informs you that the layers 
of the pleura do not as yet glide freely on each other, and that there 
is some obstruction still to the free passage of air into the air vesi- 
cles. There is also another point. When we come to inquire into 
the exciting causes of these neuroses, we observe that they are 
most generally found to depend upon various circumstances con- 
nected with improper nutrition and with moral influences. Of 
these two classes of causes, the latter, though perhaps not the most 
numerous, are by far the most remarkable. A violent neurosis 
may be brought on in a single instant by moral causes. A nervous 
female, in apparent good health, may, from a sudden fright or fit of 
passion, get an instantaneous attack of neuralgia of the liver, and 
be thrown into a state of intolerable agony. Lastly, you will be 
greatly assisted in these cases by a knowledge of their history and 
previous treatment. What you will generally find is, that the patient 
has gone through a long and harassing course of general and local 
antiphlogistic treatment. The failure of this treatment will be of 
great value in guiding you to a correct diagnosis ; and you will be . 
further confirmed in this view of the case, by finding that the 
treatment which has the power of relieving or curing consists in 
improving the state of the whole system by the use of tonic, and, in 
many cases, of stimulant remedies. These observations will apply 
to almost all cases of purely nervous affections. 



LECTURE XXXIV. 

Principles of treatment of neuralgic affections — Connection with organic disease — 
Neuralgia of the liver — Treatment — Hemicrania — Treatment — Use of iron, quinine, 
and opium — Endermic method of using opium — Tic douloureux— Opinions of Sir C. 
Bell — Remarkable case related by — Inflammation of frontal sinuses — Violent symp- 
toms — Mr. Crampton's treatment — Affections of the fifth and seventh nerves in 
cases of cerebral disease — Neuralgia of the side — Researches of Lombard and Brande 
on the effect of nitrate of silver — Injury to the skin. — [Appropriateness of the term 
neuralgia. — This disease may be caused by inflammation of the nervous sheath — 
Origin of neuralgia sometimes in the nervous centres — Change in the state of the 
nerves themselves and in their extremities — Diagnosis of neuralgia — Nerves and 
regions chiefly affected with neuralgia— the fifth pair and the dorsal and sacral nerves 
— Varieties of neuralgia specified — Dorsal or intercostal neuralgia mistaken for irrita- 
tion of the spinal cord — Its seat, symptoms, and diagnosis — Ganglionic and visceral j 
neuralgia — Treatment of neuralgia.] 

To-day I purpose to speak of some of the general principles con- 
nected with the treatment of neuralgic affections ; and here I beg 
leave to remind you, that we mean by neuralgic affections an exalta- . 
tion of the nervous sensibility independent, quoad its production, 
of any organic disease which we can detect in the nerves, brain, or 
spinal cord. There is no proposition better proved than this, that 
the phenomena of nervous affections are not the same as those of 
inflammatory diseases ; everything tends to prove it, whether we 
look to the history and sj^mptoms of the case, the results of treat- 
ment, or the appearances seen on dissection. 



NEURALGIC AFFECTIONS. 



361 



As the nervous system is diffused all over the body, and as there 
is no part of the system which does not, under certain circum- 
stances, exhibit indications of sensibility, it follows that we may 
| have neuralgic pains in any of the component tissues. Still, it is 
remarkable, that neuralgic affections are much more frequent in 
some parts than in others; and we find that, of all parts of the 
I nervous system, the superficial nerves are those which are most 
commonly affected. With respect to the nervous affections of the 
! viscera, we know very little as to their exact seat, but it has been 
! generally observed that the pain is situated in the situations of the 
j plexuses of the great sympathetic. 

In entering upon the principles which should regulate the treat- 
ment of neauralgic diseases, I have to remark that they are but 
slightly modified by their situation ; in fact, it may be stated gener- 
ally, that the same principles of treatment apply, no matter where 
j the disease may be situated. But are we to consider this subject 
as totally apart and having no connection with the occurrence of 
inflammatory or organic disease 1 If we did so, we should get but 
a limited and erroneous view of the matter. I have told you before, 
that in long-continued cases of functional disease, organic altera- 
tions were very apt to take place. The reverse of this proposition 
also is true, that organic affections may precede an attack of nervous 
symptoms ; in other words, you may have cases presenting, at first, 
phenomena amenable to antiphlogistic treatment, and yet a period 
will arrive when new symptoms occur, and this mode of treatment 
will be no longer applicable. This is of importance in the prac- 
tice of medicine, for if, in such a case, you persevere in the use of 
depleting measures, you will affect nothing towards the removal 
of distressing symptoms, and may do your patient's constitution 
much injury. A common example of this is, where a person 
receives some local injury, as, for instance, a blow on the cheek. 
This is followed by all the symptoms of inflammation, as pain, 
swelling, heat, redness, &c. Well, then, you have a case of local 
inflammation to deal with, and you must treat it as such. But a 
period may arrive when, the heat, swelling and other symptoms of 
an inflammatory affection subsiding, the pain alone continues. 
Here the pain may be purely nervous ; and if you were to go on 
leeching, purging, and depleting your patient, you would not only 
lose your time, but in all probability, do mischief. Here, as in 
I many other cases, we have local inflammation followed by an active 
j neurosis. You remember, when speaking of hepatitis, I remarked 
that many persons were subject to pains in the region of the liver, 
I independent of any known organic disease. I also drew your at- 
tention to the fact, that after the symptoms of hepatitis are removed, 
' the pain sometimes continues, having no longer any connection with 
I organic disease, and taking on the character of a neurosis. You 
| will see of what importance this is when you reflect on the mis- 
chief done to such patients by persevering in bleeding, blistering, 
! and the use of mercury, when the disease is amenable, not to this, 



362 



STOKES'S THEORY AND PRACTICE. 



but to a plan of treatment calculated to remove the neuralgia of the 
liver. It is the same thing with respect to the mammae, injuries of 
which are frequently followed by severe neuralgic affections. In 
the case of the heart, it sometimes happens that, after an attack of 
pericarditis, the patient will be subject to pain in that region, which 
may continue for years. Dr. Bright gives a very remarkable case 
of neuralgia which supervened on the disappearance of a cutaneous 
affection. All these facts tend to show, that the mere preexistence 
of local inflammation in any individual case does not prove that 
the pain is not neuralgic, and hence it is plain that in such a case 
it might be improper to persevere in the treatment used for local 
inflammation. This persisting in the taking of a neuralgic pain for 
the continuance of inflammatory or organic disease is a common 
error, and often productive of the most frightful consequences. 
Without a careful consideration of such cases, you will fall con- 
stantly into error. Never forget that although neuralgia may be 
the first and sole affection, yet, that it is often combined with 
organic disease, which it may precede, accompany, or follow. 

One of the most common forms of neuralgia which you will meet 
with in private practice, is what has been termed hemicrania, the 
chief symptom of which is violent pain in one side of the head 
and face. The symptoms are exceedingly violent ; there is a high 
degree of exaltation in the sensibility of the surface of the face ; the 
eye is exquisitely sensible to light, and the ear to sound. The 
patient is very much prostrated, and his spirits depressed, and the 
slightest cause is sufficient to bring on an attack of pain. In some 
eases the pain is constant, in some remittent, in other intermittent. 
The sensibility is deranged only at one side of the head and face, 
and the pain seldom extends beyond the median line. As far as 
we know of this affection, it seems to depend on some morbid state, 
either of the sentient extremities of the fifth nerve, or of that portion 
of the brain which receives its impressions. 

In cases of hemicrania we may have symptoms existing else- 
where, and this leads us to the consideration of the exciting causes. 
These will be often found to depend on deranged digestion. Here 
the irritation is reflected through the sympathetic system to the 
brain and sentient branches of the fifth pair, for there exists be- 
tween these two nerves a very close and remarkable sympathy. 
Thus we frequently observe, that tic douloureux, as well as hemi- 
crania, are the result of some injury or irritation of those parts to 
which the ganglionic nerves are distributed. In treating a case of 
hemicrania, then, you must inquire whether there be any visceral 
irritation present, and remove it as soon as possible. You must 
also carefully inspect the teeth and gums, for a carious tooth or a 
diseased gum will prove the exciting cause of an attack. I have 
seen many cases of hemicrania where the patient was subjected to 
a variety of treatment without success, and where complete relief 
was obtained by the simple process of extracting a carious tooth. It 
is a very curious fact, that in those instances the pain was referred, 



NEURALGIC AFFECTIONS. 



363 



not to the diseased tooth, but to the whole surface of the face. 
Cases of this kind are given in which the pain lasted for many 
years, resisting every form of treatment, and were afterwards cured 
by the extraction of a decayed tooth. There is one circumstance 
in these cases which is very apt to mislead, and this is, that the 
pain is often not referred to the tooth ; and relief, to a certain 
extent, is obtained by the use of narcotics and carbonate of iron. 
This, however, should not lead you to think that the disease has 
no connection with the state of the tooth and gum ; and this fact is 
illustrative of a most important principle, viz., that temporary relief 
by a purely anti-neuralgic treatment does not prove that no organic 
origin exists. How often has hysteria depended on local disease, 
and the practitioner been misled by the temporary relief afforded 
by antispasmodics. I have seen the most melancholy examples of 
this, and have more than once been misled myself. 

With respect to the remedies most generally employed in the 
treatment of hemicrania, they are chiefly preparations of arsenic, 
iron, sulphate of quinine, and opium. Of these, the recently pre- 
cipitated carbonate of iron appears to be the best ; indeed its success 
is frequently heroic. In proof of this you will find several very 
interesting cases detailed by Mr. Hutchinson in his excellent work. 
The best way of giving it is to combine it with an aromatic and a 
laxative ; a small quantity of the pulv. cinnamomi comp., a few 
grains of rhubarb, and fifteen grains or a scruple of the carbonate 
of iron, will form a powder which may be given two or three times 
a day with advantage. It has been asserted, that the carbonate of 
iron is suited for fixed, and not for intermittent, cases of neuralgia ; 
I have found the contrary to be the fact. I had lately a lady under 
my care, who, in attempting to remove some furniture, received an 
injury by striking her cheek against a chest. She was treated for 
six weeks with purgatives, local bleeding, and mercury; the swell- 
ing, heat, and redness of the part went off, but the pain remained, 
being regularly intermittent, and occasionally very severe. This 
lady was perfectly cured by a tonic regimen, and the carbonate of 
iron, in scruple doses, three times a day. The sulphate of quinine 
has been proposed as being peculiarly adapted for intermittent 
cases ; it will sometimes succeed, but I have known several cases 
where it completely failed. I grant that the character of intermis- 
sion would naturally induce a practitioner to have recourse to it, 
but I have known so many instances of its failure, in purely inter- 
mittent neuralgia, that I give a decided preference to the carbonate 
of iron ; I recollect the case of a gentleman who for six weeks had 
daily attacks of terrible hemicrania. When the attack came on he 
was obliged to remain perfectly motionless, the tears'streaming from 
j the eye of the affected side, the ear was exquisitely sensible to the 
j slightest sounds, and he remained in a state of intolerable suffering 
! for some hours. For the space of six weeks he took quinine in 
| enormous doses without any improvement, and was ultimately 
I obliged to give it up as useless. I have seen the same result in a 



364 



STOKES'S THEORY AND PRACTICE. 



great many cases, and as far as my experience goes, I would not 
place much reliance on quinine, even where -the attack was of a 
purely intermittent character. I have seen some cases, indeed, 
where it has done good, and you may try it ; but if, after three or 
four full doses, you find there is no improvement, you may be 
almost sure that it will prove useless. When it succeeds, one of 
the first effects produced by it is to put back the paroxysm for an 
hour or two, just as occurs when it is successfully given in a case 
of ague. But I feel certain, that if it is likely to succeed its bene- 
ficial effects will be seen in the course of a few days, and to persist 
for weeks in using it is not only unnecessary but improper. In the 
very remarkable case to which I have just alluded, the gentleman, 
after having tried quinine without the slightest improvement for 
six weeks, was suddenly and completely relieved by a full dose of 
opium. At night, on retiring to rest, he took a strong opiate, awoke 
in the morning refreshed and free from pain, and has continued 
from that time to the present (a period of ten years) without any 
symptoms of hemicrania. Dr. Mackintosh says that the sedative 
solution of opium, or the acetate of morphia, are the best remedies 
for this disease he is acquainted with, and that he has seen many 
cases where they succeeded, after everything else had failed. You 
may also employ in such cases' the external use of narcotics with 
great advantage, of which one of the best is the extract of bella- 
donna. If you prescribe a liniment composed of a drachm of the 
extract of belladonna, with an ounce of the compound camphor 
liniment, you will have a powerful remedy, and one which, when 
applied to the surface of the affected parts, will often produce great 
relief. I have sometimes used the acetate of morphia in the ender- 
mic mode, by putting on a small blister, and leaving it on until 
vesication was produced, when the raised cuticle was cut away 
with a pair of fine scissors, and the surface dressed with an oint- 
ment composed of a drachm of lard, and from a grain to a grain and 
a half of the acetate of morphia. I remember two cases of inter- 
mittent hemicrania which yielded to this treatment. You will 
also frequently derive benefit from the internal use of stramonium 
and belladonna. There are many other remedies used for this 
purpose, but I shall not detain you any longer on this part of the 
subject ; it will be sufficient to remark that the carbonate of iron, 
sulphate of quinine, and opium, externally and internally, are the 
remedies on which the most reliance is to be placed. 

We have now to consider one of the most painful affections to 
which man is subject. This affection has been generally consi- 
dered under two points of view, either as functional or organic. 
The functional, as far as we can judge of it, appears to be a pure 
neurosis; in the organic it is supposed that the disease is connected 
with an organic affection of some part of the brain ; of these the 
first kind is that most commonly met with in practice. 

Tic douloureux is one of the most melancholy and harassing 
affections to which the human frame is liable; in some instances 



NEURALGIC AFFECTIONS. 365 

the poor sufferer, after having lived for years in a state of exqui- 
site misery, is atJast worn out by the intensity and persistence of 
his agonies. Such was the fate of the late celebrated but unfor- 
tunate Dr. Pemberton. A great deal of light has been thrown on 
the nature of this affection by the researches of Sir Charles Bell. 
He seems to have succeeded in establishing several points connected 
with the nature and seat of this affection, one of the most important 
of which is, that the seat of this disease is in the sentient branches 
of the fifth pair of nerves, and not, as it has been supposed, in the 
portio dura. He has shown pretty clearly that the portio dura is 
the nerve which regulates the muscular motions of the face, pro- 
ducing all those modifications of features which we call expression, 
and also peculiar motions or changes connected with certain states 
of respiration ; in a word, that it is the expressive and respiratory 
nerve of the face. It is, according to him, never the seat of tic 
douloureux, and the practice of dividing it for this complaint is as 
unscientific as unsuccessful. The division of the portio dura in 
such cases, not only fails to give relief, but also entails disgrace on 
the practitioner, and disfigurement and misery on the patient. Its 
effect is paralysis of the muscles of one side of the face, and great 
distortion, without the slightest relief. Yet it is a melancholy fact 
that such operations have been performed. Sir C. Bell's researches 
however, have put an end to this malpractice, for he has shown that 
the fifth nerve is that which supplies the face with sensation, and 
that it is in its branches the disease is situated. We are then, I 
think, to look upon this disease as a neurosis situated in -the expan? 
I sions of the facial branches of the fifth pair of nerves. Sir C. Bell 
relates a very remarkable case, in which the patient had suffered 
from a series of dreadful attacks, the pain coming on in violent 
paroxysms. From the accounts given by this patient, and from 
personal observation, he says that one could trace with anatomical 
precision the course and direction of the branches of the fifth nerve, 
for, on the recurrence of an attack of pain, he applied his fingers to 
his face, and made pressure on the foramina, where the different 
j branches of the fifth nerve issue. Having done this, he would 
press the nerves with all his force, and remain in a fixed posture 
while the paroxysm continued. 

Sir Charles Bell's idea with respect to the cause of this disease, 
is, that it generally depends on some visceral irritation reflected 
through the sentient branches of the fifth pair of nerves. 

I have told you that this disease is one of the most melancholy 
affections to which man is subject, it is also one of the most obsti- 
nate. A vast number of remedies have been employed or proposed 
' for its treatment, and this affords an illustration of the fact, that the 
I more incurable a disease is, the more extensive is the list of its 
I remedies. A few only are deserving of attention, and these I have 
| already mentioned when speaking of hemicrania, namely, the pre* 
j parations of arsenic, iron and quinine, and opium. Where these 
fail after a full trial, Dr. Bright looks upon the case as hopeless. 

32 



366 STOKES'S THEORY AND PRACTICE. 



Narcotics in every form and of every description have been em- 
ployed, both externally and internally, but to all these the same 
remark applies ; many of these remedies will give temporary relief, 
and the physician will flatter himself on the prospect of a favourable 
termination, but in a short time he is annoyed at finding that the 
disease has returned and left the patient as bad as ever. Many a 
time have I seen a poor sufferer excited by hope on receiving tem- 
porary alleviation from the use of arsenic or iron, and sinking into 
despair when he found that his torturing malady returned, and that 
the remedies which on the first trial gave relief on the second proved 
useless. The general principles which should guide you in your 
treatment are, first, to investigate carefully whether any visceral 
irritation exists, and remove it as far as possible, taking care at the 
same time to improve the general state of the patient's health ; and 
the next thing is to allay the sensibility of the nerves of the part, 
and avoid all exciting causes. In certain cases this disease appears 
to be connected with an affection of the brain, and this seems to be 
an explanation of the fact before mentioned, that in some cases, 
where all specific treatment had completely failed, relief had been 
obtained by shaving the head and applying ice to the scalp during 
the paroxysms. I have already mentioned to you a case in which 
this mode of treatment proved eminently successful. This is a 
curious fact, and one which, being of practical importance, you 
should hold in memory. 

We have a form of disease consisting of violent paroxysms of 
pain, apparently nervous, and in which no doubt the branches of 
the fifth pair of nerves are engaged ; it is generally found to depend 
on a local cause, being connected with some disease of the bones of 
the face or skull, and bears a close analogy to tic douloureux. I 
have now witnessed several instances of this disease; in some cases 
it is produced by a carious tooth, in others by disease of the maxil- 
lary bones, and I have observed it to occur in one case of abscess j 
of the antrum. The same thing has been observed by Dr. Bright, ] 
who gives a case in which the extraction of one of the bicuspids ! 
was followed by a gush of matter, from the antrum and complete I 
relief of the violent pain. I have also seen cases in which this I 
affection appeared to be the result of disease of the lining mem- | 
brane of the frontal sinus, of this also Dr. Bright gives an example. | 
The case I witnessed was that of a lady who got a dreadful attack, 
resembling hemicrania, in consequence of being exposed to cold 
shortly after leaving a warm climate. She suffered the most violent 
agonies for some time, until one day she had a discharge of puru- \ 
lent matter from the nostrils, which was almost immediately follow- : 
ed by relief. This has recurred at intervals since that period, the 
pain ceasing when the discharge comes on, and returning when | | 
the discharge goes away. The pain is most intense, and situated j 
in the direction of the frontal sinus, and running down along the 
side of the face ; it is constant, and without any intermissions, D 
returns upon the occurrence of any cause which checks the dis- Q 



NEURALGIC AFFECTI0NS.1 367 

charge, and is sometimes so excessive as to render her quite frantic. 
Whenever an attack comes on she applies a number of leeches over 
1 the frontal sinus, then warm fomentations, and this has the effect 
J of bringing on the discharge and giving relief. In a conversation 
which I had with Mr. Crampton on this case, he stated to me that 
he had met with two similar ones, and that he had succeeded in 
accomplishing a perfect cure by inserting a large caustic issue over 
the top of the head. I accordingly advised my patient to have the 
! same thing done. She has since that time left the country ; but 
1 previous to her departure I certainly observed an improvement in 
| her symptoms, and the principle of treatment appears to be per- 
fectly rational. 

j This leads us to consider some affections of the sentient and 
' motor branches of the fifth pair of nerves, in which the disease is 
j connected with an affection of the brain. A very interesting and 
! important case bearing on this point is given by Sir Charles Bell, 
which I shall briefly relate. The patient, a lady, had remarked, 
that for twelve months before the case began to assume a serious 
j character, she felt an unusual sensation in the tip of the tongue, 
1 towards the left side, as if it had been burned. This sensation 
gradually extended over the whole of the left half of the tongue, the 
left half of the palate, gums, and face, accompanied by an almost 
total loss of proper sensation in the parts affected. The sensation 
of heat and uneasiness was increased by the least motion of the 
face, the application of her hand, and other trifling causes. This 
case was communicated to Sir C. Bell by Dr. Whiting, under 
' whose care it was. She had paralysis of the buccinator of the 
j affected side, and the morsels of food had to be removed on that 
side with the finger, so that she was obliged to perform mastication 
with the opposite jaw alone. The motions of the face, however, 
were properly performed, showing that the functions of the super- 
ficial branches of the portio dura were unimpaired, and the tem- 
poral and masseter muscles continued in their natural state. Her 
general health also was pretty good, and she complained of nothing 
but the affection of the side of the face, tongue, and palate, and the 
impossibility of masticating her food with comfort on the left side, 
in consequence of the state of the buccinator. Some time after- 
wards, while engaged in eating, she found that a new train of 
symptoms were in progress ; her face became distorted by the 
retraction of the mouth to one side, the masseter and temporal 
muscles of the left side ceased to act, the tongue became protruded, 
with its tip directed to the left side, hearing ceased on the same 
side, she had some difficulty in performing the motions of the eye, 
! and the eyeball began to waste and diminish. About a month 
I before her death she became quite stupid, and spoke very indis- 
j tinctly. She died after the disease had continued for two years. 

Here was a case, presenting in the first instance symptoms of a 
I nervous affection of the left side of the face, tongue, and palate, 
unaccompanied at that time by any paralysis of the muscles of the 



! 



36S 



STOKES'S THEORY AND PRACTICE. 



face. About a year afterwards, however, she began to exhibit 
symptoms of paralysis of that side affecting those muscles which 
are supplied by the branches of the portio dura and fifth nerve. 
Expression was now lost, the temporal and masseter muscles ceased 
to act, the mouth was drawn to one side, and the tongue protruded. 
In addition to this the sense of hearing on one side was lost, and 
the globe of the eye began to waste. On dissection, it was found 
that a tumour, appearing to be a morbid growth from the left crus 
cerebri, about the size of a pigeon's egg. and containing some fluid, 
was situated over the left temporal bone. This production was 
partly cellular and partly membranous. But the most interesting 
part of the case was the examination of the state of the nerves. 
The first and second nerves were undisturbed, and so was the 
fourth. The third was slightly displaced ; but it was on the fifth 
that the principal impression seemed to have been made, for it was 
flattened, thin, and wasted, as if from the direct pressure of the 
tumour. The sixth nerve was uninjured. The seventh was 
involved and lost in the tumour, from within a quarter of an inch 
of its origin as far as the meatus auditorius internus. Here is a 
drawing of the case ; here is the fifth nerve flattened and w 7 asted, 
and here is the seventh involved in the tumour. 

Mr. Stanley gives a case very similar to the foregoing, of which 
I shall give you an abstract. The patient had hemiplegia of the 
left side, without loss of sensation in the affected arm or leg, but in 
the left side of the face there was a complete loss of sensation and 
motion. The loss of sensation and motion in this case would argue 
that there was an injury of the seventh nerve as well as the fifth. 
The mucous membrane of the left nostril was red, and there was 
opacity and disorganization of the cornea of the left eye, with total 
loss of hearing on the same side. The patient died some time after 
the paralytic symptoms were established. On dissection, a tumour 
was found lying close to the tuber annulare, and compressing the 
fifth and seventh nerves. 

Here w 7 as a case in which there was hemiplegia of one side, and 
complete loss of motion and sensation in the corresponding half of 
the face, with an erysipelatous redness of the nostril; inflammation 
of the conjunctiva, and disorganization of the cornea. It is a curi- 
ous fact, that in cases where the sentient branches of the fifth 
nerve, which are distributed to the face, become affected, the eye 
is frequently disorganized. The cause of this appears to be that the 
eye, under such circumstances, loses the sensibility of its external 
surface, which is supplied by the branches of the fifth pair, and is 
consequently left in a state in which it can no longer protect itself 
from external injuries. In a case of this description w r hich came 
under the notice of Mr. Crampton, the finger could be rubbed over 
the eyeball without giving the patient any pain, and there was 
chronic inflammation of the conjunctiva. 

The principles which should guide us in the treatment of neu- 
ralgic affections of other parts of the body are the same as those 



NEURALGIC AFFECTIONS. 



369 



j which have been laid down in speaking of the neuralgic affections 
of the face. You will often meet with affections of this nature in 
females: they are situated generally in the right or left side, and 

j are frequently, I regret to say, mistaken for cases of local inflam- 
mation. I have already dwelt on the disastrous consequences of 

I mistaking a neuralgia of the liver for hepatitis, and showed the 
mischievous consequences of treating it with purgatives, leeching, 

1 blistering, and mercury. There is an analogous affection of the 

| left side, which has frequently been mistaken for disease of the 

| heart, and treated accordingly. It is most commonly observed in 
females of a nervous habit. To this affection, the same principles 

| will apply as to hepatic neuralgia ; by regulating the patient's 

| general health, prescribing a mild nutritious diet, giving up all 

: antiphlogistic measures, and the judicious employment of tonics and 
narcotics, you will be able to effect a cure. 

It has been lately proposed to use the nitrate of silver in the 
treatment of cases of this description, from its success in epilepsy. 
A very interesting memoir on this subject has been recently trans- 

I mitted to me from Paris by Dr. Lombard, in which he dwells on 
the utility of the nitrate of silver in several nervous affections. 

< Some persons, but in particular the disciples of the physiological 
school, think that nitrate of silver relieves cerebro-spinal irritation 
by creating a new irritation elsewhere; that its efficacy consists in 
its causing a revulsion of the gastro-intestinal mucous membrane^ 
and that thus we cure an epilepsy by substituting a gastritis. In 
proof of this they bring forward cases where a chronic gastritis, 

I was found to supervene on the removal of an epilepsy by this, 
remedy. This, however, is by no means a fair or logical deduction. 
The epilepsy might have been preceded and produced by the 
chronic gastritis, though the symptoms of the latter were not recog- 
nised, owing to the existence of other symptoms of a more promi- 
nent and striking character. The gastritis might have had a 
priority of existence, and might have been the cause of the epilepsy ;, 
the epilepsy might be cured, and the patient die afterwards with 
symptoms of chronic gastritis. This shows you how cautious you 
should be in receiving, on medical subjects, the post hoc ergo propter, 
hoc argument. This mode of explanation of the cure of one irrita- 
tion by the substitution of another, sprung from the denial of all 

i specificism, in disease and its remedies, by the school of Broussais, 
one of the greatest errors of the "physiological doctrine " The 
use of mercury in syphilis, of bark in ague, and many other 
instances have been quoted against it. If in these diseases there 
be nothing but local irritation, why does not ordinary antiphlo- 
gistic treatment always suffice for their removal ? Why is it that 
mercury is the best revulsive in syphilis'? The specific character 
appears under this view, as well as under any other. The term 
specific may be objectionable as not being precise, but we use it 
for want of a better, and it rather expresses what the disease is not 
than what it is. 

32* 



370 



STOKES'S THEORY AND PRACTICE. 



There is another and a more rational objection to the employ- 
ment of nitrate of silver; namely, that it has produced a blackening 
or discoloration of the skin. This, in my opinion, is an objection 
which will always weigh against the use of the remedy, for there 
are few who would like to encounter the risk and consequent blame 
of such an event. It has not been proved that nitrate of silver has 
cured epilepsy by superinducing gastritis, but it has been proved 
that it may blacken the skin. Dr. Lombard admits that this may 
and does occur, but he thinks the frequency of its occurrence much 
overrated, and states that in the majority of his cases it did not 
happen at all. He mentions a very interesting fact connected with 
this subject. It has been supposed that exposure of the skin to the 
influence of sunlight during the use of the nitrate of silver is the 
cause of the blackening. Now Dr. Lombard says that this cannot 
be the case, for one-half of his patients were peasants who worked 
in the open air, and never took the slightest precaution against 
exposure to the sun's rays ; and yet, among them all, there was no 
instance of discoloration. He is of opinion, therefore, that the 
influence of the sun's rays should not be taken into account in a 
case of blackening of the skin ; and this appears to be confirmed by 
the fact, that in all cases where the nitrate of silver produced dis- 
coloration, the patients were inhabitants of towns, and consequently 
less liable to exposure.. This blackening of the skin, though a rare 
circumstance, will, as long as we are ignorant of the causes which 
produce it, and the means of controlling them, be a great obstacle 
to the internal use of nitrate of silver. I have used this remedy in 
cases of epilepsy and other diseases, and cannot say much for it ; in 
the hands of some of my friends, however, it has been much more 
successful. Dr. Lombard thinks very highly of its value. In some 
cases in which he prescribed it a perfect cure followed, in others 
more or less relief. He gives some cases of facial neuralgia, in 
which it appears to have produced a cure. He has also prescribed 
it with success in epilepsy and chorea; 

There is one fact, which appears to show that the cause of the 
blackening of the skin is connected with something else besides the 
influence of the solar rays, which I had almost forgotten. In a late 
number of the Quarterly Journal of the Medical Sciences, Mr. | 
Brande gives an account of some experiments he made on the 
bodies of persons who were tinged by the nitrate of silver. He found 
on examination that the deep-seated parts were tinged as well as 
the superficial, and was able to detect the oxide of silver in the 
bones, and even in the substance of the viscera, as well as in the 
skin. If this be the case, we cannot attribute the discoloration to 
the solar rays, though it generally happens that the face appears to 
be darker than other parts of the body in persons who have 
undergone this change of colour. The fact, however, that in Dr. 
Lombard's cases the peasants escaped while the citizen became 
tinged, and Mr. Brande's discovery that the deep-seated parts are |j 
equally liable to discoloration, furnish a weighty objection to the 



[NEURALGIA.] 



371 



opinion that the blackening of the cuticle is produced by the decom- 
posing power of the sun's rays. 

[Neuralgia is a term of modern origin, for which we are indebted 
to Chaussier; and a better one could not be framed, since it simply 
expresses a fact (pain of, or in, a nerve) the chief feature in the case, 
without its being connected with or derived from any hypothesis. 
The occasional changes by injection, thickening and effusions 
of the neuriloma of a nerve affected with neuralgia, show that 
the disease may be of an inflammatory nature; but in many, and 
perhaps a majority of cases, there is no structural lesion evident. 
The chief seats of neuralgia are in the first and second branches of the 
fifth, in the sensitive portions of the dorsal nerves, and of the par 
vagum, and in the sciatic nerve. Occasionally, though seldom, the 
portio dura is the seat of neuralgic irritation. A distinction has 
been drawn between neuralgia of the nerves of animal and that of 
the nerves of organic life, in the paroxysmal returns of the former 
coming on in the latter part of the day or in the evening, and those of 
the latter early in the morning. But an exception to this rule is 
presented in the history of twenty-two cases of frontal neuralgia 
reported by Dr. Rennes, in which the attacks for the most part 
w r ere in the morning, and in sixteen of dorsal neuralgia by Dr. Val- 
leix, which came on in the day as well as the night. 

In attempting to ascertain the seat of neuralgia we are not to 
regard the part pained as that in which the primary nervous lesion 
exists. This latter may be at the sentient and percipient centre, in 
the medulla oblongata and brain, as in the instance of pain still re- 
ferred to a limb which had been long before removed by amputation, 
or strongly felt in a particular nerve during a dream, or induced 
during the waking state by strong mental emotion. All the causes 
which influence powerfully the nervous centres, such as great atmo- 
spherical mutations, moral affections, intellectual labour, prolonged 
watching, a habit of body peculiarly sensitive and nervous, may 
give rise to neuralgias. Bearing this fact in mind we are the less 
surprised at the occurrence of intense pain al.ong the course of a 
nerve whose structure is perfect, whilst, at other times, a manifest 
and great laceration of a nerve is productive of slight and scarcely 
painful sensation. Connected with this general condition of the 
nervous system, not measured by anatomical change or lesion, is 
the greater predisposition to neuralgia at particular periods of life 
more than others. The two extremities of life, infancy and old age, 
being in a measure exempt. Although the general proposition be 
admitted, that neuralgia may depend on certain unappreciable modi- 
fications of the nervous centres,— we must not stop here in our 
I inquiries, but proceed to note the vital and organic changes in the 
I nerves themselves. Organic and hygienic causes may act directly 
| on a nervous cord, increase its sensitive property or continuedly 
I work on its sensibility, and give rise to neuralgia. We generally 
| find that the superficial or subcutaneous nerves are most subject 



372 



STOKES'S THEORY AND PRACTICE. 



to this disease. Persons who by their calling are habitually exposed 
to the effects of cold and humidity, such as fishermen, sailors, 
inhabitants of marshy countries, the workers in certain manufacto- 
ries, are very liable to neuralgia : — half, that is fashionably, dressed 
females often suffer in the same way from the same cause. Physical 
and mechanical causes, by which nerves are compressed, stretched 
or pricked ; organic changes by tubercles or neuromas developed 
in their tissue, inflammations of the neurilema or in the substance of 
a nerve, making part of or situated in the neighbourhood of an in- 
flamed organ, may also all, severally, give rise to neuralgia. Of this 
last nature are the facial neuralgias which so often accompany exten- 
sive inflammation of the pituitary membrane, and the sympathetic 
pains resulting from a phlegmasia of the kidneys, uterus, and 
testicle. 

The extremities of nerves may be so impressed as to give rise to 
neuralgia — continued pressure of a boot or shoe, which is too shorty 
on the end of the great toe, will cause this disease. Of a similar 
nature is the neuralgia depending on a carious tooth and inflamed 
gum ; although this is a case which ought, perhaps, to be regarded 
as neurotis, or inflammation of a nerve, rather than neuralgia. 
There are other cases in which inflammation of the gum, as 
well as organic changes of the tooth, had long ceased, and 
yet the pain still continues, and constitute often one of the most 
troublesome facial neuralgias, or tic douloureux. Even here the in- 
fluence of the nervous centre is every now and then powerfully and 
instantaneously manifested, as when the protracted and racking 
pain of toothache disappears with the arrival, or announcement of 
the arrival, of a dentist, who comes to extract the decayed tooth. 

The diagnosis of neuralgia, although laid down by some writers 
with great precision, is not quite so easy as would appear from their 
showing. Periodicity or paroxysmal recurrence at irregular inter- 
vals, relief by pressure and friction, absence of heat, redness and 
tumefaction, and occasionally even a sensation of coldness in the part 
affected, are the common symptoms of neuralgia, whether this dis- 
ease attacks the organ of animal or of organic life. Thus, one 
almost instinctively presses the abdomen in neuralgia of the stomach 
and intestines, or in gastralgia and enter algia — whereas, if neurotis, 
or other phlegmasia be present, the least degree of pressure can- 
not be borne. The same difference is often observable in-facial 
neuralgia. But on the other hand we see at times cases in which 
the slightest touch, or even the jar communicated by shaking the 
bed or sofa on which the patient lies, gives the most violent pain. 
Writers are not careful enough to separate neurotis from neuralgia, 
nor in fact is it easy to do so, combined as these two states are in cer- 
tain cases of recognised neuralgia. Thus, Dr. Elliotson says neu- 
ralgia is very inflammatory, so that the surface is tender, hot, 
swollen, and even red. If the absence of pain on pressure were to 
be received as diagnostic of neuralgia, we should have to exclude 
from this class that large variety depending on or connected with 



[NEURALGIA.] 



373 



spinal irritation, in which augmented sensibility of the parts supplied 
by the affected nerve is one of the most constant symptoms. 

Mention has been made already of the nerves chiefly affected . 
with neuralgia. I will just add a rapid sketch of the chief varieties 
of the disease, in reference to the regions affected and the organs 
which are the greatest sufferers. The nervous centres themselves, 
at least the sentient part of them, may be the seat of neuralgia, the 
pains of which are felt at the surface and envelopes of the brain 
and spinal marrow, rather than in the substance of the organs them- 
selves. In this respect there is an analogy to what takes place in 
the neuralgia of a nervous cord, the symptoms of which are felt at 
the extremity or expansion of the nerve on the surface of the organ. 
Cephalalgia, therefore, which "we use instead of cerebralgia, may, 
like neuralgia of the cords and their extremities of the nerves, be 
dependent on or associated either with simple irritation or phlogosis 
— an important consideration which it behoves us to bear in mind 
in practice. In delirium tremens and certain other varieties of 
cerebral disease, there is more cerebralgia than cerebritis, and we 
ought not to be misled by pain, and exaltation and disturbance of 
function under such circumstances, so far as to take them for une- 
quivocal symptoms of inflammation. Opium and narcotics, if our 
diagnosis be a correct one, would take precedence over, and be 
substituted for the lancet, leeches and purging. I might, did 
space permit, illustrate this proposition by describing the pheno- 
mena of myelalgid, and show that these were manifested at a 
distance from the medulla spinalis, sometimes by exquisite tender- 
ness of the skin of one or more limbs, and of the muscles of parti- 
cular regions, sometimes by subsequent irregularity of movement 
consequent on morbid sensation, as in certain changes of the voice, 
spasms of the oesophagus, convulsive cough, dyspnoea, vomiting, 
colics and cramps. Most of the neuralgic affections, however, which 
have been attributed to a morbid state of a part of the spinal cord, 
proceed, as I shall have occasion soon to show, from the spinal nerves, 
and particularly the intercostal. In all these affections of the cord 
or its nerves, the neuralgia so far predominates over neurotis, that 
we shall often find counter-irritation and anodynes suffice for entire 
relief without having had recourse to sanguineous depletion. 

The neuralgias of th e encephalo-spinal nerves are — 1, the frontal 
or supra-orbitar, the pains of which beginning at the supra-orbitar 
foramen extend to the upper eyelid and eyebrow, and the corres- 
ponding side of the forehead and face, following all the nervous 
ramifications and anastomoses of the orbito-frontal nerve. Some- 
times the pain is fixed on the nasal arch and frontal sinus, or on 
the ramifications of the nerve over the globe of the eye, constituting 
I in the first place a coryza, and in the second ophthalmodynia, 
\ or an eye painful, watery, and intolerant of light, with com- 
| monly some tenderness of the conjunctiva. Frontal neuralgia is 
i usually intermittent, and sometimes merely remittent, — the pa- 
roxysm coming on daily in the evening, lasting a part of the night, 



i 



374 



STOKES'S THEORY AND PRACTICE. 



and disappearing towards morning and during the day. At other 
times, and particularly where the disease is either associated with 
disease of the chylopoietic viscera, oris brought on by the common 
causes of intermittent fevers, the paroxysm is4n the morning. Dr. 
Rennes (Eclectic Journal of 'Medicine, 1836-'7 ', from the Archives\Gen- 
erales, June, 1836,) describes thirty-two cases of the disease depending 
on atmospherical vicissitudes, and occurring in a rural district, and 
at the same time with influenza, which were of this nature. 

2. Sub-orbitar neuralgia.— This kind is described by writers 
under the names of jwosapalgia and odontalgia. As its title indi- 
cates, it affects the sub-orbitar branch or superior maxillary of the 
fifth or trifacial nerve. The pain radiating from the sub-orbitar 
foramen, is sometimes continued in the line of the muscular branches 
of the face, sometimes in that of the deeper seated or dental branch, 
and extends, in the first instance, to the lower eyelid, the interna! 
angle of the eye, the cheek, the ala nasi ; and, in the second, to 
the maxillary sinus, the palate, uvula, base of the tongue, and often 
to the whole side of the face, following the anastomoses of the fifth 
with the ramifications of the portio dura of the same side. In this 
case the pain is apt to be accompanied by convulsive twitchings of 
the lower eyelid, cheeks, and upper lip: — the arteries of the affected 
side beat with more force, but not, as has been commonly asserted, 
with more frequency; the veins are more dilated, and sometimes 
we see all the symptoms of a true fluxion, such as redness of the 
eyes and face, tumefaction, of the eyelids, and an abundant excretion 
of tears and nasal mucus. 

This variety of neuralgia exhibits the intermittent type ; some- 
times it is remittent ; but in either case its paroxysmal returns are 
in the evening. At times the neuralgia is confined to a single twig 
of the superior maxillary branch, and hence the names given to each 
of these sub-varieties of sub-orb ito-nasal, labial, palpebral, and 
dental. 

3. Maxillary neuralgia. — In this variety the pain follows the 
course of the inferior maxillary branch of the trifacial or fifth 
nerve, and consequently extends not only from the superior mental 
foramen to the alveoli, lower teeth, sides of the tongue, and to the 
chin, but also may be irradiated over the cheeks, temples, and the 
external and anterior portion of the ear, by following the anastomoses 
of the nerve with the ramifications of the portio dura in this 
region. The right side is more frequently affected than the left. 
This neuralgia is less evidently periodical than those already de- 
scribed, but like them may be sometimes accompanied by partial 
convulsions and deformity of the mouth and eyelids. Facial 
neuralgia, complicated with muscular contractions, though less 
painful, is generally more obstinate than simple neuralgia. To 
these sudden and jerking movements, as it were, of the muscles, 
the term tic has been applied, and the sensations accompanying 
it caused it to be qualified with the epithet douloureux, or painful. 
When the neuralgia affects chiefly the alveoli and roots of the teeth, 



[NEURALGIA.] 



375 



it simulates closely toothache— the more readily, because a carious 
tooth will give rise to both diseases, which may also, notwithstanding 
the persistence of the cause, be periodical, and yield to remedies 
j directed against periodicity. 

4. Neuralgia of the Cord of the Tympanum* — This variety, de- 
scribed by Itard under the name of otalgia, more particularly 
attacks children, and sometimes adults, in connexion with facial 
neuralgia. The intermission of pain, its darting and divergent 

i character, the absence of fever and of other symptoms of phlogosis, 
! distinguish it from internal otitis. The introduction of a little 
| soothing balsam, or even sweet oil and two or three drops of lauda- 
! num, or an injection of warm water, will often suffice for its cure. 

5. Cervical neuralgia. — This is of rare occurrence. Sometimes 
it has been caused by bleeding the jugular vein, and by the bites 
of leeches to the neck. 

6. Thoracic and Intercostal Neuralgia. — Under this head are 
I properly included those neuralgic pains affecting the mammae, 

shoulders, thorax, and hypochondriac and epigastric regions, and 
which are connected with, or as it has of late years been generally 
thought, originate from spinal irritation itself, manifested by tender- 
ness of one or more vertebrae on pressure. Omitting, as either 
generally known or not germain to our present purpose, a notice of 
the essays which have appeared within the last twelve years, on 
both sides of the Atlantic, on the subject of spinal irritation, neu- 
ralgia, functional affections of the spinal cord, &c, I am fortu- 
nately able to indicate, with more precision than has hitherto been 

! attempted, the seat and character of the kind of neuralgia now 
under consideration, by borrowing from the very clear and de- 
tailed essay by Dr. Valleix, in the Archives Generales de Medicine 
for January and February of the present year. 

The title of the disease examined by Dr. Valleix is dorsal or 
intercostal neuralgia. When pointing out the fact of the roots of 
the dorsal nerves being much higher than the point of their exit 
from the vertebral canal, he takes occasion, from this anatomical 
fact, to expose the inaccuracy of the English writers, who attribute 
the disease in question to irritation or any .other lesion of the spinal 
cord. The pain caused by pressure on the spine, according to their 
own description, exists always at the posterior end of the intercostal 
space, in which last is found the painful point in front. It is then 
at the very exit of the nerve, and in a line with the intervertebral 
foramen, that we discover the pain. Were the irritation really of 
the spine, we ought to detect the pain at. the origin of the nerve, 
and consequently at a spot higher up than the foramen. Each 
dorsal nerve at its departure from the intervertebral foramen is 

j divided into two branches ; one, posterior, goes directly back- 
wards, and gives off filaments variously distributed, some of which, 
and they the ones most interesting in the present question, pass 
between the transverse processes and the muscles which cover 
them, and are distributed to the skin of the back. The anterior 



376 



STOKES'S THEORY AND PRACTICE. 



branch is, properly speaking, the continuation of the nerve. That 
of the first dorsal nerve comes out below the first rib, and that of 
the twelfth, below the last or twelfth rib. It is important for us to 
know that this branch is not subdivided in any notable manner 
until towards the middle of the intercostal space : at first it is situ- 
ated beneath the intercostal muscles, and is only covered internally 
by the pleura ; then it is engaged in the muscles, and passes 
between them until it has reached the middle of the intercostal space, 
where it divides in the manner just indicated. The ramifications 
are not distributed in a uniform fashion. Thus, in the first three 
dorsal nerves there is an intercostal branch which continues in the 
original direction, or rather towards the inferior part of the inter- 
costal space, and another branch which goes to the upper limb. 
The eight following dorsal nerves furnish, also, an intercostal branch, 
which is continued in the original course, and only penetrates the 
muscles which cover it at a short distance from the sternum, or 
from the outer border of the external part of the great abdominal 
oblique muscle, whence it distributes its filaments to the integuments 
of the anterior part of the chest and superior of the abdomen. In 
place of a brachial branch as was given out by the first three 
nerves, these eight furnish each of them an external pectoral branch 
which penetrates the external intercostal muscle, and distributes 
filaments to the integuments. The last or twelfth dorsal nerve is 
appropriated to the muscles and integuments of the abdomen, and 
is divided into a superficial and a deep-seated abdominal branch; 
a division this analogous to that of the preceding nerves. 

In summing up these anatomical details, the application of which 
will soon be obvious, we find that the dorsal nerves have three prin- 
cipal divisions, — the first immediately after their exit from the 
intervertebral foramen, — the second about the middle of the inter- 
costal space, measuring from the spine to the sternum ; — and the 
third a little external to the sternum or to the upper part of the 
rectus muscle. Thus at each of the points of division there is a 
branch which is superficial and gives twigs to the integuments. 
There are three of these perforating branches, — one anterior, near 
the sternum; a second, or middle, the name of which indicates its 
situation, — and a third, or posterior. 

Under anatomical guidance we can now speak more understand- 
ing^ of the seat of dorsal or intercostal neuralgia. As to the side 
which is chiefly affected we find notable differences. In sixteen 
cases noted by M. Valleix, the neuralgia was on the left side in 
eight; the right in four ; and in both sides in four. With the ex- 
planations offered by the author, such as the relatively slight nature 
and early subsidence and disappearance of the pain of the right 
side, — the proportions would be in fact, he thinks, in the left side, 
eleven cases ; right side, four ; in both sides, one. M. Nicod, the 
only writer who had examined this subject in a methodical manner 
before M. Valleix, makes the proportion in which the two sides 
were affected, as 15 of the left to 1 of the right. 



[ NEURALGIA. ] 



377 



The number of the intercostal spaces occupied by the neuralgia 
varies from 2 to 8. This last number was only met with in two 
cases. Frequently (six times) there were but two of the spaces 
affected ; and if we were to take a mean term expressive of the 
whole, it would be three and a fraction. But even when a con- 
siderable number of intercostal spaces were the seat of neuralgia, 
more commonly two or three of them, and generally the sixth and 
seventh, were much more sensitive than the others, and appeared 
to be the centre of the pain. To extend the proposition a little 
more, we might say, as the result of a table given by M. Valleix, 
that dorsal neuralgia would seem to display itself in preference, on 
the fifth, sixth, seventh, eighth, and ninth intercostal spaces, and 
that in an especial manner it is met with most frequently from the 
sixth to the ninth — a result very nearly the same with that 
announced by M. Nicod. 

The spaces which were the seat of pain were in no instance 
affected through their whole extent, at least during the entire 
course of the disease. In speaking of neuralgic pains, we ought, 
however, to state separately, the pain caused by pressure, that 
caused by various movements, and that felt spontaneously in cer- 
tain dragging, pricking, and darting sensations. The latter some- 
times extended over the whole space. Three principal parts were 
the seat of pain on pressure, — the vertebral or posterior point was 
always sensitive, viz. : in 16 cases, — the anterior point in 14 ; the 
middle in 12. The posterior or vertebral point is on one of the 
sides of the spinal column, between two vertebras, and precisely at 
the spot corresponding with the intervertebral foramen. This 
painful spot was of circumscribed extent, varying from half an inch 
to an inch and a half. Hence it happens, that at a very short dis- 
tance from a point at which pressure gave great pain, considerable 
force might be used without exciting any unpleasant sensation. 
This fact will be referred to when we speak of the diagnosis. The 
direction of the line of pain from the posterior point was always 
forwards, and neither backwards on the vertebras, nor upwards or 
downwards on the spinal processes. 

The median point at which pain on pressure was felt, is, as the 
latter indicates, the middle of the antero-posterior direction of the in- 
tercostal space, or rather in the prolongation of a vertical line drawn 
from the axilla to the crest of the ilium, for the first five or six 
intercostal spaces, and an inch or an inch and a half farther back 
for the lower ones. The median space was also circumscribed 
like the posterior was found to be; its limits being from half an inch 
to an inch and a half. In the cases in which the pain extended 
! more than half an inch it was in the longitudinal or antero-posterior 
j line, and consequently in the course of the nerve, as in the case of 
, the posterior point. 

As to the anterior point, the pains was more variable and mul- 
j tiple even than the preceding ones. In the fourteen cases in which 
it was met with, pressure gave rise to it at a point not far from the 

33 



i 

i 



378 



STOKES'S THEORY AND PRACTICE. 



sternum, and always between this point and the beginning of the 
. cartilaginous portion of the ribs. But the extent of the space affected 
was hardly greater than that of the posterior and median spaces. 
A variety in the point affected in this last or anterior division is 
worthy of being recorded : it is in the epigastric location, or rather 
termination of the pain. Thus, when pressure on the spaces be- 
tween the cartilages was productive of pain, if it was continued for- 
wards under the angular curvature, and on the epigastrium, for an 
equal breadth, the pain was equally felt. This line of direction of 
pressure, of course passed over some of the cartilages of the ribs, 
and there was an interruption accordingly in the course of the pain 
between the inter-cartilaginous point and the epigastric point, for a 
space equal to the breadth of the cartilages. The limitation of the 
region of epigastric pain, and its line of direction from the anterior 
and inner point, externally and outwardly in the track of the inter- 
costal nerve to the spine, will serve to distinguish this neuralgia from 
gastritis. 

The painful spots above indicated, are so not by pressure alone, 
but even in consequence of strong inspirations, cough, movements 
of the arms and sometimes of the trunk ; and the darting pains them- 
selves had commonly their point of departure from these spots, 
which we may regard as so many centres of pain from which it 
radiated in the course of the nerve. 

An explanation of the occurrence of pain at these spots is 
furnished by the anatomical details already premised. Thus, back- 
wards at the exit of the nerve from the intervertebral foramen a 
branch is detached which traverses the muscle, and is distributed 
to the skin ; here is the first painful spot or point. Towards the 
middle of the intercostal space the nerve becomes also superficial, 
and detaches another branch which passes on to the ligaments, 
giving a second spot for painful sensation. Finally, at the anterior 
spot near the sternum and towards the epigastrium, the nerve again 
comes nearer to the surface than before, and distributes its filaments 
to the integuments of the anterior part of the thorax, making the 
third painful point.* 

A complaint of pain in any part of the chest, without cough, 
or even at the epigastrium, will therefore induce the physician 
to run his finger down with a moderate pressure on each side of the 
spinal column, at the spino-costal junction and in the direction of 
the intervertebral foramina. If there be an intercostal neuralgia, 
the patient shrinks from pressure at the affected point, and cries out 
at the pain which he experiences. By continuing the pressure 
downwards, the physician arrives at a line beyond which no posi- 
tive sensation is felt, and he thus has the limits, upper and lower, of 
the spine affected with neuralgia. By next passing his finger in a 

* I have at the present time a case under treatment, in which the symptoms 
correspond precisely with those here detailed. The seventh, eighth, and ninth 
intercostal spaces are the ones affected, and the epigastric pain terminates exactly 
at the median line. The right is the side affected ; pressure on the spine itself is 
not productive of pain. 



[ NEURALGIA. ] 



379 



line from the posterior point of pain in the fisrt intercostal space 
affected to the sternum, he learns the direction and limits anteriorly 
of the disease. 

Mr. Valleix was not led to any positive inference respecting the 
causes, either predisposing or occasional, varying from the received 
1 opinions on the subject. It was found that the most frequent com- 
plaints of pain were in snowy weather, even by patients in their 
1 rooms, and returns of the disease most common in winter. The 
! duration of the neuralgia was from one to six months ; and where 
1 it assumed an intermittent character the disease returned at inter- 
j vals from one year to four years, whether remedial means were 
■ had recourse to, or whether at each return the pain was left to dis- 
appear of itself. 

The differential diagnosis of intercostal neuralgia has been already 
! stated incidentally. We distinguish the disease from affections of 
j the respiratory organs by means of auscultation and percussion, 
and by taking cognizance of the seat, direction, and limits of the 
pain; and from rheumatism of the muscles of the thorax, by re- 
j membering that the pain in this latter is more diffused, less acute 
1 under pressure, and more so by motion. Angina pectoris has been 
thought to depend on intercostal neuralgia, but it is distinguishable 
from this latter by its paroxysm, and the feeling of constriction and 
j agonising distress which accompanies it. The diseases of the spinal 
I cord cause sometimes a local pain, which is situated on the spinal 
| processes and not on the sides. In caries of the vertebra?, pressure 
' on the ribs, by these latter acting on the diseased bone, causes pain 
I at the spine, which is not the case in neuralgia. 

I resume the enumeration of the different varieties of neuralgia, 
by mentioning lumbar neuralgia, which has been called, by Chaus- 
sier and others, ilio-scrotal and spermatic, and, by some, lumbago. 
It may occupy one or several of the different lumbar branches, and 
be felt, according to the extent of these nerves, in the loins, at the 
crest of the ilium, and over the great trochanter, or along the 
spermatic cord, in the scrotum, vulva, bladder, urethra, &c, giving 
rise to a crowd of symptoms calculated to render the diagnosis 
obscure. I have had recently under care a young person with this 
kind of neuralgia, in whom the symptoms of disease of the bladder 
were such as to induce fears of gravel associated with those of 
prolapsus uteri — all of which disappeared by the removal of the 
lumbar neuralgia. In another case there were so many of the 
symptoms of prolapsus uteri present, that I deemed it my duty to 
i recommend an examination per vaginam. Somewhat to my sur- 
I prise the uterus was high up, perfectly in situ, but painful to the 
! touch. A persistence, however, in the remedies which had been 
i already prescribed for the lumbar neuralgia, which also was present 
I in this case, was followed by entire relief of all pain and abnormal 
j sensation whatever. The patient has since then become pregnant, 
i for the first time, after a marriage of some years' duration. 

It will be sufficient to mention some other varieties of neuralgia, 
without making any additional remarks on them. These are the sea* 



380 



STOKES'S THEORY AND PRACTICE. 



pular or deltoidean ; the cubito-digital, which extends from the olecra- 
non to the index and middle fingers ; the femoro-pretibial or anterior 
crural. The femoro-popliteal, or sciatic neuralgia, demands more at- 
tention by its frequency of occurrence, its obstinacy, and the agonis- 
ing pain with which it is every now and then accompanied. Under 
the name of sciatica it is usually spoken of as one of the varieties of 
rheumatism. I am not sure that general experience will correspond 
with the opinion advanced byM. Joliy, (from whose article nevralgia 
in the Dictionnaire deMid.etdeChirurgie Pratiques,! have taken so 
largely,) that sciatica is more common in women than in men, owing 
to the causes of pregnancy and labour of child-birth operating on the 
former. The nerve is, no doubt, in different states in different per- 
sons, and at different times in the same person — its neurilema being 
sometimes inflamed and thickened, and sometimes containing gela- 
tinous effusions, by all which the nerve proper must suffer. At other 
times again, this latter is intact in its structure, and the affection is 
then one of simple neuralgia. In the first case cups or leeches on 
the hips and behind the great trochanter or on the outer side of the 
thigh, with other parts of an antiphlogistic treatment, will benefit if 
not cure. In the second, the customary modifiers ot sensibility, 
especially narcotics and tonics, must be the chief curative agents. 

Plantar neuralgia is occasionally met with, and is not a little annoy- 
ing to the patient, who complains of a pain in the sole of his foot to 
which the plantar portion of the popliteal nerve is distributed. 

Neuralgia of the nervous extremities where they are lost in, or 
blended with the tissues are common enough, as in neuralgia of the 
muscular tissue, which is not at all connected with inflammation, 
but is met with in the onset of certain typhoid fevers, acute 
gastro-enteritis, and in the chill of an intermittent fever, or from sup- 
pressed perspiration, atmospherical changes, &c, and which are 
commonly designated as rheumatic: akin to this variety is that at- 
tacking the fibrous and osseous tissues, and which are attributed, 
and, in fact, are occasionally caused by syphilis, mercury in excess, 
scurvy, &c. 

Neuralgia of the serous tissues shows itself, sometimes in violent 
pain of an intermittent character, attacking the meninges of the 
brain, the pleura and the peritoneum, but which yield readily to 
quinine and opium. 

Neuralgia of the mucous tissues comes, for the most part, within 
the list of ganglionic neuralgia ; but we have examples of it on sur- 
faces which belong to the cerebro-spinal system, as in the pituitary 
membrane, the conjunctiva, the bronchia, and the large intestine, 
&c. The skin is occasionally the seat of violent pain without in- 
flammation, just as the parenchymatous tissues are. 

Although their course and extent be indicated with less precision 
than already specified, the neuralgias of the organs supplied by the 
sympathetic nerve or ganglionic system, cannot well be doubted. 
Bichat had early, in this path of inquiry, expressed an opinion that 
there are colics essentially nervous, independently of any local 
affection of the serous, mucous, and muscular coats of the intestines. 



[ NEURALGIA. ] 



381 



These colics have obviously, he continues, their seat in the nerves 
of the semilunar ganglion which are distributed along the whole 
course of the abdominal arteries; they are true neuralgias of the 
nervous system of organic life, although they have nothing (little) in 
common with tic douloureux, sciatica, &c. Ganglionic neuralgias, 
like those of the other order, are intermittent, but less distinctly so 
than these. They are accompanied often with a great fluxion and 
discharge of fluids, as of urine, bronchial mucus in asthma, hooping- 
cough and suffocative catarrh, — hence also, probably, the deluge of 
fluid in cholera morbus, dysentery, &c. 

In the nervous system of a mixed nature, that which connects 
the two lives, organic and animal, although it belongs more parti- 
cularly to the latter, and which is sometimes called the nervous ap- 
paratus of association, we meet with marked examples of neuralgic 
diseases. Pneumogastric neuralgia may result from direct irritation 
of the nerve itself, as in the phlegmasia? of the pulmonary and gastric 
mucous membranes: it is manifested by a convulsive cough, 
spasms of the air-passages, and of the diaphragm and stomach. Or 
it may be the effect of a sympathetic irritation transmitted from 
some remote organ by the medium of the ganglionic plexus, as in 
inflammation of the kidneys, testicle, and uterus, or even simple 
pregnancy, which will give rise to dyspnoea, or to obstinate vomiting, 
with acute and tearing pains of the epigastrium. Finally, pneumo- 
gastric neuralgia may, like all the neuralgias, depend on some lesion 
of the nervous centres. Of this nature are intermittent asthma, 
periodical coughs, nervous dyspnoea, and vomiting. Gastralgia is a 
variety of this kind of neuralgia, and either appears alone or is 
recurrent, and constitutes the chief symptom of some pernicious 
intermittent fevers. 

Diaphragmatic neuralgia is manifested by pains, more or less 
acute, with a constriction at the epigastrium and back, accompanied 
with hiccup, eructations, and vomiting. This may readily be con- 
founded with rheumatism and inflammation of the diaphragm, of 
which I shall speak in a subsequent part of this volume. 

I have not much to say on the treatment of neuralgia in addition 
to the judicious remarks of Dr. Stokes. This should be based on a 
knowledge of all the circumstances, physical, hygienic, and physiolo- 
gical, which have any influence in the production of the disease; 
and should include, of course, a just appreciation of its seat and its 
idiopathic or symptomatic nature. I have dwelt the more on the 
various seats of neuralgia, and the symptoms by which its varieties 
are recognised, because, in so doing, I believed that I was conveying 
most valuable instruction to the younger portion of my medical 
brethren, by teaching them to shunthe common, I mightsay, barbarous 
empiricism which confounds pain and derangement of function with 
inflammation, and prompts to blood-letting, purging, and the heroical 
generally in place of the narcotic and soothing treatment. 

Every resident in marshy and low situations is aware of the com- 
monness of intermittent pains, hernicrania, frontal and facial neu- 
ralgia, ophthalmia, sciatica, &c, which sometimes accompany inter- 

33* 



382 



STOKES'S THEORY AND PRACTICE. 



mittent fever, and sometimes succeed to or are substitutes for it. 
The successful employment of the bark in former times and quinine 
now, is also pretty well known to the practitioner in such cases. 
I have found, on occasions, the local detraction of blood by means 
of a few cups or leeches beneficial under these circumstances, 
both by the relief which they gave, and the speedier and more 
complete effect subsequently of quinine. Arsenic has, I know, 
been administered often in these intermittent as well as some of the 
more untractable remittent fevers of neuralgiee. Without intending 
to prohibit its use, I still think that a physician who administers it 
to his patient ought to give approved security that he will not injure 
the stomach of the latter, by bringing on chronic gastritis and its 
accompaniments. 

In cases of feeble action of the organs generally, or of a sensa- 
tion of coldness at the part affected, stimulants are indicated-, and 
of these ammonia, camphor, and guaiacum are entitled to confi- 
dence : — The ammoniated tincture of guaiacum is a favourite pre- 
scription with some, — exhibited in such quantities as to keep the 
patient comfortably warm. With this view, a dose of half a 
drachm, or even four times the quantity, has been given and re- 
peated three times daily, and sometimes every two hours. Where 
there is debility, with paleness, iron is, in Dr. Elliotson's opinion, 
preferable to quinine. My own experience is different. Mercury 
carried to ptyalism has cured : but unless the subject have some 
strength, and a certain degree of excitement, he will only be more 
depressed and positively injured by such a course. Of the narcotics, 
the extract of stramonium, which we can so readily procure fresh 
in the United States, is entitled to fuller and more frequent trials 
than it receives ; externally, also, in the form of tincture, or oint- 
ment spread as a plaster, it will be a good topical application to the 
affected part. When given, the stramonium should be continued in 
such a dose and at such intervals until its peculiar and marked 
effects on the brain and nervous system are produced. The most 
opposite means have been used with occasional success, as in one 
instance steam, in another ice. Dr. La Roche of this city suc- 
ceeded in allaying and completely removing the pain of acute and 
protracted sciatica, which had resisted various remedies directed 
with no common skill and experience, by the application of ice over 
the affected part. The patient went to sleep shortly after it was 
put on. Oil of turpentine in divided doses, so that a drachm or 
two be used daily, has been found to be very successful in a num- 
ber of cases of sciatica, and in some other varieties of neuralgia by 
M. Martinet ; and the same medicine in a full dose of half an ounce 
to an ounce by enema has been used with advantage. 

Veratria and its salts and aconitine are certainly entitled to consi- 
deration, notwithstanding the unmeasured praise lavished on them by 
Dr. Turnbull ; for assuredly the practice has been retarded by the in- 
discreet zeal of its advocate. In one case of tic douloureux in a lady, 
in which I had employed quinine, and iron and opium, after purgatives 
and alteratives, with only partial relief, an ointment, composed of 



[ NEURALGIA. ] 



383 



twenty grains of veratria and an ounce of lard, was directed 
to be rubbed on the affected cheek, and in a short time with a 
most satisfactory result. The common proportion is ten to twenty 
grains lo the ounce of lard or cerate. The cure was complete ; and 
there has been no relapse up to the present time, which is upwards of 
three years from the date of the treatment. The sensation of heat 
and tingling was experienced by my patient shortly after rubbing 
in the ointment. Dr. Turnbull gives these symptoms as an evidence 
of the desired operation of the veratria, and, indeed, of its genuine- 
ness. A neater preparation is the alcoholic tincture, which is to 
be applied to the skin over the affected part. Quite recently I have 
seen this latter manifestly alleviate facial neuralgia in the case of a 
lady who used it at my suggestion. Of the internal use of veratria 
and its salts, and of delphinia and aconitine, which have been also 
recommended in neuralgic and rheumatic affections, I am not pre- 
pared to speak from personal experience. The dose of veratria, or 
of tartrate of veratria, the salt preferred by Dr. Turnbull, is a sixth 
of a grain in pill with half a grain of extract of hyosciamus, and 
some convenient vehicle, such as liquorice powder, — repeated three 
times a day. For the last two ingredients rhubarb should be substi- 
tuted, when there is costiveness. The dose may be gradually in- 
creased to a grain and a half or two grains in the course of the day.* 
That variety of neuralgia which is most common and, in refer- 
ence to its extensive symptoms, the most important in the eyes of a 
practitioner, is the dorsal or intercostal. Under the name of spinal 
irritation it has been commonly, and I cannot but think success- 
fully, treated with counter-irritation, by means of a small blister 
over the most painful spot and kept discharging, or by tartar 
emetic ointment or croton oil, and tonics, notably quinine, 
preceded by, and alternating with laxatives. In many instances, 
the first step has been to detract some blood by means of cups or 
leeches applied near the affected part. Of the advantages of this 
latter prescription I can speak with much confidence, based upon 
repeated experience. I must add, however, that although the 
relief was in most cases in which I directed it immediate, yet this 
remedy was far from removing the disease, and I am not sure that 
it materially abbreviated its duration. Dr. Valleix found small 
blisters applied in the course of the affected nerve, and renewed at 
short distances, or on the painful points, to be the most successful 
remedy. Muriate of morphia applied endermically only served in 
his experience, to allay temporarily the pain. He did not find blis- 
tering or leeches to cure the neuralgia ; but, on the contrary, they 
seemed to aggravate it. Narcotics, quinine and iron, were not 

; productive of any notable result. 

The reader can refer with profit to a paper on Tic Douloureux, 

, drawn up in detail and with great fulness by Dr. Chapman, in vol. xiv. 

; of the American Journal of Medical Science. In the same volume 

j there is an account, by Dr. Thomas Harris, of several cases of 

* Dr. Turnbull's Essay on the Medical Properties of the Natural Order Ra- 
nunculacece is republished in the Select Medical Library, 1838. 



i 

! 



334 



STOKES'S THEORY AND PRACTICE. 



facial neuralgia, some cured, others greatly mitigated by galvanism, 
applied through the apparatus directed by Mansford. The success 
which has attended the use of this agent in Epilepsy as well as in 
Neuralgia, and in the former, I may add, that spirits of turpentine 
is the internal remedy entitled to most confidence, induces me to 
copy a description of the apparatus and its mode of application, as 
given by the English writer in his work on Epilepsy. 

" It was said, that in order to fulfil the indication stated at the 
commencement of this section, it was desirable to establish a nega- 
tive point as near the brain as possible, and a positive one in some 
distant part of the body. Accordingly, a portion of the cuticle of 
the size of a sixpence being removed by means of a small blister 
on the back of the neck, as close to the root of the hair as possible, 
and a similar portion in the hollow beneath, and on the inside of the 
knee, as the most convenient place: to the wound in the neck, a 
plate of silver, varying according to the age of the patient, from the 
size of a sixpence to that of a half-crown, was applied — having 
affixed to its back part a handle or shank, and to its lower edge, and 
parallel with the shank, a small staple, to which the conducting wire 
was fastened. This wire descended the back till it reached a belt 
of chamois leather, buttoned round the waist — it then followed the 
course of the belt, to which it was attached, till it arrived opposite 
the groin on the side it was wished to be used ; it then passed down 
the inside of the thigh, and was fastened to the zinc plate in the 
same manner as to the silver one. The apparatus so contrived was 
thus applied: — a small bit of sponge moistened in water, and cor- 
responding in size to the aperture in the neck, was first placed 
directly upon it — over this a larger piece of sponge of the same size 
as the metallic plate, also wetted, was laid — and next to this the 
plate itself, which w r as secured in its situation by a strip of adhesive 
plaster passed through the shank on its back, another above, and 
another below it. If these be properly placed, and tiie wire which 
passes down the back be allowed sufficient room that it may not 
drag, the plate will not be moved from its position by any ordinary 
motion of the body. The zinc plate was fastened in the same man- 
ner — but in place of the second layer of sponge, a bit of muscle 
answering in size to the zinc plate was interposed : that is, a small 
bit of moistened sponge being first fitted to the aperture^ below the 
knee, the piece of muscle* also wetted then followed, and on this 
the plate of zinc. The apparatus thus arranged will continue in 
gentle and uninterrupted action from twelve to twenty-four hours, 
according to circumstances. This last is the longest period that it 
can be allowed to go unremoved : the sores require cleaning and 
dressing, and the surface of the zinc becomes covered with a thick 
oxide, which must be removed to restore its freedom of action ; this 
may be done by scraping or polishing: but it will be better if re- 
moved twice a day, both for the greater security of a permanent 
action, and for the additional comfort of the patient." — B.] 

* A piece of soft buckskin is more cleanly than the muscle and equally as 
efficacious. 



SCROFULA. 



385 



LECTURE XXXV. 

Scrofula ; former opinions on — White and red capillaries — Division of the system into 
red and white tissues — Vascularity of the white tissues — Dr. Graves's views of the 
lymphatics — Analogies of lymphatics and veins — Meckel, Cruikshank, and Magen- 
die's opinions on — Relations of the circulating and nervous systems — Vitality of 
serous membranes — Reproductive power of white parts — White blood and white 
tissues more prevalent in women than men — White tissue more liable to cancer, &c. 
— Analogy of the white parts with cold-blooded animals — Increased sensibility of 
white tissues — True nature of the scrofulous diathesis — Reference to arrest of 
development — Explanation of its phenomena— [Connection between phthisis and 
scrofula not so evident — Causes of scrofula — Damp and impure air the chief cause — 
Physiognomical traits of scrofula— Treatment, general and local — Scrofulous tumours ; 
applications to — Enumeration of tissues and organs the seat of scrofulous disease 
— Modifications of inflammation by scrofulous diathesis — Principles on which 
the treatment is based — Depletion not prohibited — Mercurials, how to be used — Other 
alteratives — Tonics and narcotics.] 

In the varied catalogue of morbid affections to which man is 
liable, there is scarcely one of such paramount importance, such 
engrossing interest, as scrofula — whether we look to the obscurity 
of its origin, its insidious progress, the number and variety of the 
organs which it attacks, or its remarkable intractability and exten- 
sive fatality. It is, indeed, a subject of deep concern to every one 
who is engaged in the pursuit of medical knowledge ; and I do 
therefore entreat your undivided attention while I endeavour to 
give you some clear ideas as to the meaning of what has been 
termed the scrofulous diathesis, and scrofula itself. 

It is now generally admitted, that a great proportion of our im- 
proved knowledge on the subject of scrofula, as well as many other 
diseases, has been the result of those splendid anatomical and patho- 
logical investigations which have distinguished modern times. The 
older authors knew little of pathological or comparative anatomy; 
and hence it was that scrofula, on which pathology has shed such 
a broad and searching light, was to them an intangible essence — 
something which they knew to exist, but could neither portray nor 
define. If w 7 e look to what their opinions were on this subject — 
opinions which, I regret to state, are not yet sufficiently exploded 
— we shall find that they are based on the then prevailing doctrines 
of exclusive humoralism; and that, instead of attempting to reduce 
the phenomena of scrofula to a fixed and tangible formula, they 
sought to explain it by referring to certain peccant and noxious 
humours in the system. But, in order to arrive at accurate notions 
on this subject, we must begin with the first formation of the human 
body ; we must trace scrofula back to its primal source, and care- 
fully explore its anatomical constitution. 

If we examine the capillary circulation in its physiological state, 
we shall find two kinds of circulating fluids : one distinguished by 
its red colour, and called blood ; the other transparent and whitish, 
or colourless, and termed lymph. In fact, we have two kinds of 
capillaries — one containing fibrin and colouring matter blended 
with an albuminous fluid, the other circulating only a colourless 



366 



STOKES'S THEORY AND PRACTICE. 



fluid containing little of no fibrin, and almost identical with serum. 
This is a fact which is now generally admitted. It has been sup- 
posed that the red and white capillaries differ only in point of size ; 
and this is rendered probable by the fact, that, in cases of inflam- 
mation, vessels which previously contained only a colourless fluid 
become dilated, and are rendered capable of transmitting red blood. 
This goes very far in support of the doctrine, that the red and 
white capillaries differ only in respect to size. Let us take a few 
out of many examples of this kind. The circulation of the serous 
membranes in their healthy state is entirely white, but in an inflam- 
matory condition we can, with the greatest facility, trace numerous 
red vessels ramifying through their substance, as you may observe 
in inflammations of the arachnoid, pleura, peritoneum, and other 
white tissues. You may see the same also in the case of a mucous 
membrane — as in that of the conjunctiva where it passes over the 
transparent cornea. This condition subsides with the disappear- 
ance of the inflammatory action. 

These investigations, however, as to the cause of the difference 
between the red and white capillaries, are not of great moment in a 
pathological point of view ; it will be sufficient for our purposes 
merely to admit this difference, and bear chiefly in mind the rela- 
tive compositions of the fluids which circulate through them. One 
of these, as has been already stated, is called blood, and contains a 
quantity of fibrin and colouring matter ; the other is termed lymph, 
and is chiefly composed of water and albumen : the former is cha- 
racterized by the presence of fibrin, a highly animalized product as 
containing a large proportion of azote ; the latter consists of mate- 
rials of an inferior degree of animalization, and in which we can 
scarcely detect the existence of azote. Recollecting this remarkable 
difference in the nature of the circulating fluids, we find, when we 
come to examine the solids of the body, that some organs are sup- 
plied with red blood, while others receive only white blood, and 
hence the grand physiological division of the body into red and 
white tissues : the red containing fibrin and colouring matter, and 
endowed with great vitality ; the white containing chiefly albumen, 
and possessing vital power in a comparatively weak and imperfect 
degree. To give an example of this, let us take the muscular 
fibre, (which may be looked upon as the most highly vitalised of 
animal products,) and we shall find that its tissue is red, it is sup- 
plied by red vessels, and exhibits an acute sensibility to external as 
well as internal stimuli. On the other hand, we observe that the 
white tissues — such as cartilage, tendon, and serous membrane — 
have a white and albuminous fluid circulating through them ; that 
they are of an inferior organization, and of a lower degree of vital- 
ity ; and that, in a state of health, they are almost insensible to 
ordinary stimuli. 

In order to prove the close connection which exists between the 
white tissues and a white circulation, it is necessary that we should 
admit that these tissues are vascular ; and on this point it must be 



SCROFULA. 



387 



confessed* there is some difference of opinion among physiologists. 
I Some say that the serous membranes and other white tissues are 
■ not supplied with vessels and nerves like other parts of the body, 
but that they are to be considered as a mere exudation. This is 
the opinion of Rudolphi. This notion, however, does not appear 
to be founded on truth ; it has been disapproved by the investigations 
of many eminent physiologists, but by none more than by Dr. 
! Graves in his excellent lecture on the lymphatic system. Let us 
| inquire, briefly, whether it be true that these tissues are supplied 
! with vessels containing white blood. That such is the case appears 
j from the fact of the sudden development of red vessels in those 
! tissues when in a state of inflammation. Now, it cannot be sup- 
posed that an irritation which has lasted only for a few minutes 
could be capable of forming new vessels. That vessels already 
formed might become dilated in a very short space of time, we can 
easily conceive ; but that they should start into existence in the 
I space of a few minutes, is totally incomprehensible. The sudden 
appearance of these vessels does not by any means prove that they 
are new creations ; it rather tends to show that they must have 
' existed previously to the attack of inflammation which rendered 
them visible, and that they escaped observation before that occur- 
rence, from their extreme minuteness and from the colourless 
nature of the fluid they contained. The next thing to be adduced 
in support of this view of the question is this : that parts uncon- 
nected with any red tissue shall themselves become red under the 
influence of the inflammatory process. Thus, in a case of pleuritis, 
for instance, we observe that the lymph which has been effused 
becomes gradually organized, and ultimately converted into the 
serous membrane, forming those bands of adhesion with which you 
are all familiar. At certain periods of this process, vessels carrying 
red blood may be distinctly seen shooting through the lymph, which, 
you must bear in mind, is surrounded on all sides by the original 
serous membrane. These vessels are sometimes of great size ; I 
have seen them, in a case of peritonitis, as thick as a crow-quill. 

As the organization advances to completion, we find that these 
vessels disappear, and a colourless serous membrane is formed. 
Now, here we have a newly organized tissue, presenting the same 
characters as serous membrane, and having no connection what- 
ever with any red tissue ; and yet it is not less curious than true, 
that, if this new tissue be attacked with inflammation, it will become 
] distinctly red, and will have red vessels developed in the substance 
which may be examined and traced with the naked eye. The red 
vascularity of the synovial membrane, when inflamed, may be also 
I quoted in proof of the same fact ; for this, you will recollect, is a 
j white tissue, super-imposed on other white tissues, the cartilage 
| and capsular ligament. In addition to this, we have an argument 
drawn from the great similarity which exists between the serum of 
the blood and lymph. Dr. Graves believes that the lymphatics* 
which are supposed to act merely in carrying back the debris of 



388 



STOKES'S THEORY AND PRACTICE. 



the system, really enjoy a higher function ; that they are to be re- 
garded as the veins of the white tissues, or, in other words, that 
they are to the w 7 hite arteries of the white tissues what the veins 
are to the red arteries of the red tissues. He brings forward many 
striking analogies between the veins and lymphatics. Both have 
valves, the effect of which is to direct the contained fluids towards 
the centre of the circulation ; in both the fluid flows with an 
equable current toward the heart, and in both its course is directed 
tow r ard the organ where it is destined to undergo the process of 
aeration. Dr. Graves quotes Cruikshank and others to show that 
lymphatics, coming from a white organ or tissue, become capable, 
in the inflamed state of that organ, of carrying red blood ; and this 
is a strong argument in proof of his opinions. We find, too, that 
the white blood, like the red, is separable into a watery portion and 
a crassamentum. If anything else were necessary to show the 
close connection between the veins and lymphatics, it is furnished 
by the fact of their numerous anastomoses — a fact which has been 
placed beyond all dispute by Meckel, in his magnificent work on 
the lymphatics, which he has dedicated to his illustrious country- 
man, Soemmering. Lastly, it has been shown, by Magendie, that 
the veins and lymphatics discharge a similar function — both being 
engaged in carrying on the process of absorption. Both, then, 
have a similarity of structure ; in both the contained fluids flow in 
an equable current toward the heart, and are destined to be sub- 
mitted to the same process of aeration; both contain a fluid sepa- 
rable into a clot and a watery portion ; under the influence of the 
inflammatory process, the one carries red blood as well as the 
other ; they are intimately connected with each other by innumer- 
able anastomoses, and both are alike engaged in discharging the 
functions of absorption. 

It may be admitted then, I think, that the white tissues are vas- 
cular, and that the lymphatics are the veins of the white tissues. 
Now, pursuing this investigation further, if we examine the differ- 
ent organs and parts of the human body, we find that most of 
them are composed of a combination of red and white tissues, but 
that some consists of white tissue alone. Thus, if we look to the 
constitution of muscular substance, we find that it is composed of 
muscular fibre which is a red, and celjular membrane which is a 
white, tissue. In the parenchymatous organs we find the same 
combination of red and white tissues present. But, on the other 
hand, we observe that serous and synovial membranes, ligaments, 
tendons, aponeuroses, and cartilages, have no mixture of red tissue 
in them, and are composed of white tissue alone. The fact is, 
that both enter into the composition of most of our organs, but in 
some the white tissue prevails exclusively. The same conforma- 
tion is observed in all the vertebrated animals, but particularly in 
the mammalia and birds. Now, admitting this, it appears that the 
proportion of red solids is in the ratio of the red fluids, and that 
of white solids in the ratio of the white fluids. This proposition 



SCROFULA. 



380 



we can establish by a number of indisputable facts. In the higher 
classes of the mammalia, the red solids and fluids are found in great 
abundance in the viscera, as well as in the muscular parts. In 
birds the quantity of red blood is great, and consequently we find 
the muscular substance red and firm, the circulation active, and 
the temperature high. In the amphibious animals the flesh is paler, 
the quantity of red blood diminishes, and, as the red tissues disap- 
pear, the white increase in proportion. Descending in the scale 
we come to fishes : here we find that the quantity of red blood is 
very small, and that the white tissues predominate. When we 
arrive at the invertebrated animals, or those wJio have no spinal 
system, we observe a disappearance of the red fluids and red tis- 
sues. I shall here beg leave to read for you an extract from Dr. 
Graves's lecture. "The view already taken of the intimate con- 
nection, in all the different classes of animals, between the develop- 
ment of the white parts and that of the lymphatic system, is easily 
explained on the supposition of the lymphatics being the veins of 
the white parts. In invertebrated animals, which have no red 
blood, it would be more rational to call the vessels conveying the 
white blood back to the heart lymphatics than veins; for it is more 
consistent with analogy to suppose, that, in the lower animals, the 
retained portion of the circulating system corresponds with the 
former, as in the superior animals the lymphatics are connected 
with parts which, in their degree of vitality, most resemble the struc- 
tures of the lower animals. 

"In the higher classes of animals there are not only two circu- 
lating systems — one of red blood, and the other of white blood — 
but also a twofold system of nerves, the cerebral and the ganglionic ; 
the latter of which, in invertebrated animals, seems to perform all 
the nervous functions necessary to their state of existence, while 
these animals are remarkable for possessing only a simple vascular 
system. 

" We find, therefore, a correspondence between the vascular sys- 
tem of red blood and the nervous system of the brain and spinal 
marrow. They are most perfect in animals most abounding in 
highly aerated red blood, and decrease according to the descending 
scale proportioned to the decrease of red blood, until at last we 
arrive at the invertebrated animals possessing no red blood, and no 
brain or spinal marrow." — Op. cit, p. 24. 

These facts seem to establish the law, that the proportions of red 
and white solids are in the ratio of their respective fluids. But let 
us consider this question in a different point of view. The human 
foetus, in the earlier periods of its existence, presents the appear- 
ance of a white mass without any red tissue or red vessels — in fact 
it resembles one of the lower or white-blooded animals ; but, as the 
process of development goes on, the red fluid begins to appear, and 
the red tissues increase; as it progresses towards perfection, these 
changes become more manifest, until at length, having arrived at 
the summit of the zoological scale, the predominance of the red 

34 



S90 STOKES'S THEORY AND PRACTICE. 



tissues is established, and even the new-born infant exhibits the 
distinguishing characteristics of that being which holds the first 
rank in the order of vertebrated animals. 

We have seen that, in proportion as the animal rises in the scale 
of being, the proportion of the red to the white tissues is increased ; 
and that the lowest animal, who possess only a white circulation, 
enjoy a degree of vitality not far removed from that of the vege- 
table kingdom. Red blood, then, is the pabulum vitce — the charac- 
teristics of superior organization and vitality — the rich stream by 
which the nobler parts of our system are nourished. Applying 
this to the different states of our bodies in health and disease, we 
find that the predominance of red blood and red tissues is a proof 
of health and vigour, while that of white blood and white tissues 
shows the feeble and unhealthy individual. Before we pursue this 
further in its application to the investigation of disease, let us refer 
for a moment to some illustrations. In the Albinos the white tis- 
sues are more abundant and the quantity of red blood smaller ; the 
muscular fibres are lax, and the constitution delicate. Again — 
compare woman with man. In the former the white tissues are 
more prevalent than in the latter, the skin is fairer, the vessels car- 
rying red blood smaller, and the muscular system less developed. 
Women have more white blood and white tissues, and consequently 
their strength is less, and their constitution more delicate. Again, 
if we examine the hybernating animals, who pass long periods of 
time without taking food, we find that, at the termination of their 
hybernating season, their strength is remarkably reduced, and their 
tissues much paler than under different circumstances. The same 
diminution in the quantity of red blood and red tissues, and cor- 
responding increase in the relative quantity of white tissues, occur 
in the case of persons advanced in life. From some cruel experi- 
ments made in France, it appears that, by starving animals, their 
tissues became blanched in a remarkable degree, and they came to 
represent animals of an inferior grade, so far as the preponderance 
of white tissue was concerned. These considerations are highly 
interesting and important, and remind us of Lord Bacon's aphorism, 
that white is the colour of defect. 

We may, then, conclude that the white tissues are less highly 
animalized than the red, and of a lower degree of vitality; and, 
arguing ti priori, we would say that they are less able to resist 
death, and that in them disease would be slower and more obstinate 
than in the red tissues. Such, too, is the fact, for we find that the 
white tissues are most liable to morbid affections of an intractable 
character, frequently terminating in the total destruction of the dis- 
eased parts. Cancer, tubercle, ulceration in the cartilages, liga- 
ments, or cellular substance — all these belong to the affections of 
white tissues. All these terrible inflictions are to be met with in 
those tissues which rank low in the scale of vitality ; they occur in 
persons of weak habit and diminished vital energy, and in whom 
the white tissues predominate over the red ; and they are less under 



SCROFULA. 



391 



the influence of those curative means which are ordinarily employed 
in the treatment of disease of the red tissues. Thus we find that 
many of the means, which are employed with such good effects in 
dispersing inflammations of red parts seem to possess very little 
j power in removing the disease of white parts. In making these 
observations I have spoken only in reference to chronic disease ; 
| but let us turn to the acute diseases. Here we arrive at a very 
I curious fact. If we take, for instance, the serous membranes, we 
shall find that, although strictly belonging to the class of white 
tissues, they are, nevertheless, very liable to acute and violent 
| diseases. It appears strange that parts, possessing only an inferior 
degree of vitality, should be subject to such frequent and violent 
attacks of inflammation. Such, however, is the fact. It is very 
difficult to explain this apparent anomaly; I shall, however, throw 
out a few considerations which strike me on this point, having pre- 
mised that you are to look upon them, not as proved, but lying 
open to future investigation. 

If we examine the pathology of serous membranes, we shall find 
that they are liable to inflammation in proportion to the quantity of 
red vessels in the organs they cover ; or, in other words, the more 
they are connected with organs enjoying a high degree of vitality, 
the more they are subject to inflammation. If we take the serous 
membranes lining the three great cavities of the body, we shall 
find that this position is, to a certain degree, borne out by the facts. 
One of the most common cases of inflammation is that of pleurisy ; 
i we seldom open a body without meeting with evidences of its 
existence at some period or other of the life of the individual. Now, 
we know that the lung is the most vascular organ in the body, and 
I that through it alone the whole of the circulating blood is trans- 
mitted. Next in order to the pleura, we "have the peritoneum — 
peritonitis being a much more common affection than arachnitis, 
for the intestines receive a greater quantity of red blood than the 
brain. Among the viscera of the three great cavities, the brain is 
the whitest, and receives the least blood, and we accordingly find 
that its investing serous membrane is least liable to attacks of acute 
inflammation. We have also a number of curious facts with respect 
to the nature of the connection which exists between any inflamed 
parenchymatous organ, and the serous membrane by which it is 
covered. Thus, in a case of hepatitis, we find that that portion of 
serous membrane which invests the liver exhibits traces of inflam- 
' mation, while the rest of the peritoneum remains in its normal and 
healthy condition. You will see the layer of the peritoneum 
: covering the liver in a state of inflammation, and will frequently 
I find adhesions between it and the corresponding portion of the 
parietal layer, but no other sign of extension of inflammation. This 
! fact is strongly in favour of the connection between the inflamma- 
tions of serous membranes and of the organs they cover. There is 
i another form of partial peritonitis which is exceedingly common — 
namely, the inflammation of that portion of it which embraces the 



I 



392 



STOKES'S THEORY AND PRACTICE. 



uterus, and which is so frequently met with in puerperal fever. 
Now, here we have two considerations to bear in mind. During 
utero-gestation, there is a remarkable development of the uterus ; 
and, about the period of delivery, it is a vast red organ, having a 
powerful determination of blood to its substance, as well for its own 
support as that of the infant. We accordingly find that after 
delivery peritonitis frequently sets in — its occurrence being favoured, 
in the first place, by the connection between the peritoneum and a 
large vascular red organ, and, in the next place, because the deter- 
mination has not yet ceased, and the blood which went to the 
uterus (but cannot do so any longer to the same extent) seems to 
be directed to the peritoneum. Another consideration bearing on 
this point is, that, when lymph has been effused in the case of in- 
flammation of serous membranes, the process of organization and 
cure goes on the more rapidly, the nearer the inflamed membrane 
is to a red and vascular organ. If we take a case of pleuritis with 
effusion of lymph and serum, when is it that we find the process of 
organization set up in the effused lymph? It is when the fluid has 
been removed by absorption, and the two serous layers of the 
pleura are no longer prevented from coming in contact ; for, as 
long as that portion investing the lung is separated from the costal 
pleura, either no .organization at all takes place, or, if it does, it 
is of a slow and imperfect character. But as soon as the effused 
serum is removed, and the costal pleura come into close apposi- 
iion with a red and highly vascular organ, the lymph immediately 
undergoes a process of rapid organization. The high degree of 
vascularity of the lung should be reckoned as one among the 
causes of the great frequency of pleural, as compared with peritoneal, 
adhesions. 

A question may be asked here, connected with the idea that serous 
membranes possess only a low degree of vitality. If the vitality of 
serous membranes be of an inferior kind, why is it that their in- 
flammations are so acutely painful? This, I must confess, is a 
question not easy to be answered. There is no doubt, however, 
that during the existence of inflammatory affections the vitality of 
these parts is considerably increased. They are elevated in the 
scale for the time. Their vessels carry red blood, their sensibility 
becomes exquisite, and they enjoy a reproductive power, as is shown 
in the case of the formation of new synovial membranes, capsular 
ligaments, and serous membranes; thus, as Dr. Graves has beauti- 
fully remarked, showing an analogy of organization and function 
between the white tissues of the higher, and the whole constitution 
of the lower animals, in whom the power of reproducing parts is 
so remarkable. This circumstance seems to be strongly in favour 
of Broussais' doctrine, that inflammation is nothing more than a 
plus degree of local vitality. Some persons think that the pain in 
serous inflammation depends upon the density and unyielding 
nature of the affected membranes, for you are all aware that one 
of the effects of inflammation is at first to distend the inflamed 



SCROFULA. 



393 



organ. This may be true. Again, it is said that we are also to 
take into account the extensive and constant motions of the serous 
membranes. As long as respiration goes on in the chest, or diges- 
tion in the belly; while the ribs are elevated and depressed, and 
while the diaphragm descends, or while the peristaltic action of the 
intestines goes on; there will be motion in the serous membranes 
which invest their respective viscera. We know, also, that the 
brain enjoys a certain degree of motion. We must, then, in ac- 
counting for the pain of serous inflammation, take into considera- 
tion the dense structure and little distensibility of the parts, as well 
as their constant and uniform motion. There is one fact, however, 
which, as far as it goes, is of importance, and should not be forgot- 
ten when we consider the motions of serous surfaces in reference to 
pain. Of all the serous membranes, the pericardium is that whose 
motions are most constant and violent. Yet I have now seen many 
cases of its inflammation, where quantities of lymph were effused, 
as detected by the stethoscope and by dissection, yet in which no 
pain whatever existed. 

It appears to me that we can add something to these views, in 
the way of explanation. When lecturing on hepatitis, I drew your 
attention to the fact, that if we compare the inflammations of the 
different solid viscera with respect to pain, we find that there is 
always less pain when the inflammation affects the central parts of 
an organ than when it is superficial. In deep-seated pneumonia 
there is scarcely any pain, in pleuro-pneumonia the pain is often 
acute. In arachnitis the pain is violent, in deep-seated disease of 
the brain there is frequently no pain at all. Inflammation of the 
central parts of the liver is generally a painless affection ; but, when 
it approaches the surface, it is always accompanied by more or less 
suffering. Now, if we consider the serous membrane of the 
abdomen, for instance, to be an organ of low vitality and inferior 
sensibility, we must seek for some other explanation of the pain 
which attends superficial inflammations of viscera. The following 
idea may be of some assistance towards an explanation. Let us 
take, for example, a case of inflammation occurring in one of the 
glandular viscera. You are aware that Muller has reduced the 
structure of all glands to one formula, that is to say, — a gland, in 
its simple state, consists of a cavity, shut at one end and open at 
i the other, and the difference between the various glands does not 
depend on any departure from this rule, but on a difference in the 
mode of aggregation and arrangement of these little structures. 
You will have a notion of the structure of glands by comparing 
them to a bunch of grapes, the grapes representing the glandular 
part, and the stalks their excretory ducts. Now you are aware 
I that in most glandular organs the secreting portion is placed 
| towards the circumference, and the ducts accumulate towards the 
| centre ; and, as the glandular portion alwa}'s possesses a higher 
I degree of vitality than the ducts, we can understand why the 
j superficial parts of a glandular organ may be endowed with a 

34* 



394 



STOKES'S THEORY AND PRACTICE. 



higher sensibility than the deep-seated or central, and, consequently 
that inflammation affecting the superficial parts of glandular viscera 
will be attended with more pain than when seated towards the 
centre, and affecting the excretory portion of the organ. 

We are now, gentlemen, prepared to enter on the consideration 
of scrofula, on which much error still prevails, notwithstanding all 
that has been said and written on the subject. One great cause of 
the confused notions respecting .scrofula arises from the circum- 
stance, that some persons have understood the term as expressing 
mere local disease, as, for instance, of the glands of the neck, and 
having no reference to any peculiar constitutional diathesis; while 
others use it with reference to a peculiar condition of the system, 
which is called the scrofulous diathesis; and a third class apply 
the term scrofulous to a number of very opposite diseases, which 
have no character in common but chronicity and incurability. 

By considering the subject physiologically, we escape those errors 
and acquire more accurate ideas as to its real nature ; and, as far 
as I can see, we cannot help adopting the opinion of Broussais, — 
that scrofula implies nothing specific ; but, simply, that there is an 
undue preponderance of the white over the red tissues, and that, in 
such persons, there is of course a greater liability to diseases of the 
lymphatic system. Where there is an undue preponderance of the 
white over the red tissues, there we have the scrofulous constitution, 
and the liability to its accompanying disease. Observe, there is 
nothing specific in this ; an individual, originally free from scrofula, 
may afterwards be subject to it, and it may, under certain circum- 
stances, occur in all constitutions. 

The characteristics of what has been termed the strumous habit 
are known since the time of Galen. The skin is white, the com- 
plexion delicate and transparent, the hair fair in general, but some- 
times dark; the features delicate, the upper lip thick, the alaeof the 
nose large, the head fully developed, the chest rather narrow, the 
joints large, a great tendency to sanguineous congestions, internal 
and external, which are very little under the influence of antiphlo- 
gistic means; the intellectual faculties early developed and of a 
higher order, great refinement, and delicacy of taste. In such per- I 
sons there is generally a considerable preponderance of the white ! 
tissues, and they are much disposed to scrofulous disease, which is 
nothing more than a chronic irritation of the white parts and of the 
organs immediately connected with them. 

We may look on the scrofulous diathesis as a condition of the 
human body which is to a certain degree imperfect, and which is to 
be attributed to arrest of development. There is a period of foetal 
life, in which the whole mass of the body consists of white tissues. 
According as the individual progresses towards maturity, the red 
tissues become more abundant; and when he arrives at maturity 
of maturation the proportion between the tissues becomes completely 
altered, the red being now more abundant than the white. But if 
this process should happen to be arrested, either shortly after birth 



SCROFULA. 



395 



or during life, we have then an individual of a lower degree of 
vitality, and approximating to the class of white-blooded animals. 
That we may reduce the scrofulous diathesis to arrest of develop- 
ment seems to be borne out by other considerations. We find in 
persons of a strumous diathesis proofs of arrest of development in 
various parts, so that whether we consider the question as to the 
development of the whole or of particular parts of the body, the same 
conclusion obtains. Scrofulous children have large heads, and it has 
been long known that they are exceedingly subject to hydrocephalus. 
The great size of the head in this. instance is reducible to the prin- 
ciple of arrest of development ; and here we have some explanation 
of the fact of the activity of the intellectual powers in scrofulous 
persons. Again, scrofulous children have large bellies ; and here 
we have another proof of the arrest of development. In the foetus 
the belly is larger in proportion than it is in the adult ; and if the 
individual grows up with this predominance, it is a proof of arrest 
of development. The liver in the foetus is, as you all know^, 
very large. Now it is a fact that many persons of a scrofulous 
habit grow up with this foetal condition of the liver ; and, accords 
ingly, we find this organ enlarged, not as the result of disease, but 
because an equal and proportionate increase of other parts has not 
gone on ; and here we have another fact confirming the principle 
of arrest of development. Scrofulous children are observed to have 
small limbs and contracted chests. Here, too, we again meet with 
the foetal condition. In the foetus the chest is small and contracted, 
and the extremities are puny and ill-developed. How beautifully 
this tallies with the state of the lung at that period of life when 
there is very little employment for the thorax, and when the active 
functions of the lung have not as yet been called into operation. 
This, too, informs us, why it is that such children are so liable to 
affections of the lungs. We find that scrofulous persons are of a 
feeble frame, and have weak and flabby muscles; and, in accord- 
ance with this, we find on examination that the muscular system 
to a certain degree represents the condition of foetal life, that the 
blood is albuminous, and its proportion of fibrin small. We observe 
that scrofulous children are subject to rickets, and that the propor- 
tion of phosphate of lime in their bones is small. Now this is pre- 
cisely the condition of the bones in the foetus. Thus whether we 
look to the whole or to particular parts of the body, we find that 
scrofula is reducible to arrest of development, and that there is not 
in it any virus, anything particular or specific, as has been erro- 
neously imagined. To these considerations it might be added, 
that nothing is more common than to see those monstrosities, dis- 
tinctly referable to local arrest of development, occurring in the 
scrofulous subject; and the statistics of monstrosity show that in 
this respect the female sex predominates over the male. 

There has been much disputation as to the question whether 
scrofula be hereditary or not. You can easily solve this question 
by reflecting on what you have already heard. No doubt it is often 



396 



STOKES'S THEORY AND PRACTICE. 



so ; one or both parents may be scrofulous, and it is as natural that 
a child born of such parents should inherit their scrofulous constitu- 
tion as that it should resemble them in features. But, on the other 
hand, we sometimes find that scrofulous parents beget healthy- 
children. This appears to be an anomaly, but it may be explained 
by the circumstances of the child having a good healthy nurse, 
living in pure air, having comfortable warm clothing, all cir- 
cumstances calculated to develope the red tissues, and of course 
strengthen the system. Thus a scrofulous taint may be completely 
worn out in a few generations. It sometimes, on the other hand, 
happens that healthy parents may have children of a strumous habit. 
This, however, is the rarest case, but can be explained by reference 
to causes which would disturb the balance of development, and a 
person of an originally sound constitution may, under certain cir- 
cumstances, become scrofulous. Children may be badly fed and 
have insufficient clothing ; they may be kept confined, and deprived 
of free air, light, and exercise; they may have an early irritation 
of the digestive system, from bad and unwholesome food, and 
in this way may acquire the scrofulous character without any 
hereditary disposition. Thus we come to the fact, which has been 
so frequently noticed, that scrofula will often pass over a genera- 
tion, and that the grandfather and grandson may labour under it, 
while the sun escapes its infliction. 

It may be objected to this view of the question, that we frequently 
observe persons of dark hair and robust constitutions falling victims 
to scrofula. This is certainly true, but it is not on that account 
an .argument calculated to militate against the doctrines which 
have been propounded on the subject. There are many causes 
capable of producing this increase in the white tissues, this pecu- 
liar state of the constitution, which we call the scrofulous diathesis. 
Excessive mental or bodily exertion, all the depressing passions, 
injuries of innervation of various kinds, deprivation of light, air, 
and exercise, early and continued gastro-intestinal irritation, per- 
sistent and exhausting diseases, — all these have a tendency to 
impair the functions of nutrition and to destroy the balance be- 
tween the different tissues of the body. If we look to those animals 
in which tubercles are found, we see that they are often those 
which have been brought from a hot to a cold climate, and kept in 
a state of confinement for a longtime, and hence it is that we so 
often find fatal turbercular disease in animals which are kept for the 
purposes of exhibition, The same liability to tubercle is observed 
in several of our domestic animals kept in unhealthy situation 
and deprived of air, light, and exercise. The truth is, that a com- 
bination of such causes will generate scrofula in constitutions which 
were originally sound and good; but it will occur at an earlier 
period and with much more certainty when these causes are 
brought to act on persons in whom there is an original or con- 
genital predominance of the white tissues. This fact is so well 
known as to require no further illustration ; it is now generally 



[ SCROFULA. ] 397 

I 

admitted, and you will have many opportunities of verifying it in 
practice. 

Allow me in concluding this subject, to direct your attention to 

I the following considerations. If we are to connect the pheno- 
mena of scrofula with a predominance of the white tissues, it would 
follow that woman would be more liable to the disease than man. 

I Louis, in stating the relative liability of the sexes to consumption, 
makes the proportion of males to females as 70 to 92. Cancer, 

! which is also a disease of the white tissues, is, you all know, much 
more frequent in women than men. 

Scrofula, then, to use the term as expressing local diseases, seems 
to have in it nothing of a specific character, or reducible to the 

| supposition of a virus existing in the system ; it seems to be a slow 
irritation of the lymphatic system, occurring in persons who have 

| a predominance of white fluids and white tissues. It would appear 

I also, that this predominance of white tissues may be either con- 
genital, or it may be acquired, and that, in this case, it is superin- 
duced by various causes, all having a direct tendency to diminish 

I the proportion of red tissues, and lower the vitality of the system. 
This, which appears to me to be the true meaning of what has been 
termed the scrofulous diathesis, you will find to be borne out by a 
multitude of facts, and you will have numerous opportunities in 
practice of proving the value and importance of this view of the 
question. In this way we get rid of that mode of treatment which 
was based on the supposed specific nature of scrofula, and of which 

( the object was the removal of an imaginary virus, and we are guided 
to the knowledge of a more philosophical and more successful line 
of practice. We arrive thus at the few and simple, but grand and 
efficient principles, in the treatment of scrofula ; we see that scrofula 
is in its nature closely connected with the predominance of white 
and the diminution of red tissues, and we accordingly find that our 
curative means must embrace everything calculated to invigorate 
the system, and add to the existing sum of vitality. 



[The preceding lecture, on Scrofula, abounds chiefly in the 
4 Theory' of the subject, more so indeed than is usual with Dr. 
Stokes. I may, therefore, without presumption, make some addi- 
i tional observations on the 4 Practice.' 

Great stress has been laid by some writers on the alleged con- 
nexion between scrofula and phthisis pulmonalis ; and we are told 
by them that the latter is in fact but a modification of scrofula, in 
i which the disease spends its force on the lungs. That the two dis- 
1 eases acknowledge causes in common — such as deficient nourish- 
! ment, confinement, damp and impure air, and certain other de- 
I pressing agents, we can readily admit ; that the whole tissues suffer 
I in both, is also pretty evident. But the inference, that scrofula and 
I consumption are different degrees of the same morbid process ope- 
j rating on different organs is not so clear. Mr. Phillips, in a course 
of lectures on Surgery, recently delivered at the Westminster Hos- 



I 
I 



398 



STOKES'S THEORY AND PRACTICE. 



pital School, remarks on this point : " By far the larger portion of 
the cases of scrofula are presented before the age of puberty. The 
great majority of cases of tubercular phthisis are presented after 
eighteen. Of seventeen cases of scrofula where life had been 
destroyed by the exhaustion attendant upon profuse discharges from 
ulcerated surfaces and scrofulous caries, only one presented consi- 
derable tubercular deposition in the lungs, and only nine presented 
a trace of it. Of eighty-six cases of tubercular phthisis, only one 
presented any cicatrix or other evidence in the neck, the axilla or the 
groin, of having suffered from disease in the lymphatic ganglia in 
these several regions. Louis's experience is somewhat different ; of 
358 cases of tubercular disease of the lung, examined by him, 30 
were found to present more or less traces of the deposition of simi- 
lar matter in the lymphatic ganglia. But even if we assume this 
to be an average, considering the frequency of both diseases, it is 
not too much to presume that they were simple coincidences. 

" It is also true," as Mr. Phillips remarks in reference to the lo- 
calities of the two diseases, " that the countries other than our own 
(England) where scrofula is most rife, Holland, Dauphiny, the 
Valais, the Vivarais, and certain portions of Brittany, present a 
smaller number of cases of phthisis than other countries where 
scrofula is more rarely seen. In the whole of the Oceanic region 
extending from La Teste to Mimigan, this remarkable fact obtains 
— the coincidence of extreme frequency of scrofula with excessive 
rarity of tubercular phthisis." 

The direct or immediate effects of deficient and bad food are not 
so evident as we might at first suppose, in the production of scro- 
fula. This cause, when continued to the second generation, will 
have effected such a change in the growth of the tissues, and deterio- 
ration in the nutritive functions, as probably to develope the disease, 
more especially if the depraving operation of bad air have been 
concurrently active. A friend of Mr. Phillips furnished him with 
the following results obtained from one parish in Witshire (Eng- 
land) : " There are in this parish forty-nine families, the heads of 
which earn seven, eight, or nine shillings per week. The number 
of children in these families amounts to one hundred and fifty-three ; 
they have many of them scarcely rags to cover them ; they scarcely 
get any animal food, and live principally on what would seem to 
be an insufficient quantity of coarse bread, potatoes, and some but- 
ter-milk. Of these children only three presented any of the usual 
symptoms of scrofula." Compared with this is the picture of a 
London population given by Mr. Phillips himself. In four courts 
in the parish of St. Marylebone, I have found ninety-three families, 
containing two hundred and one children, the greater number run- 
ning about, some engaged as errand boys ; very few with shoes or 
stockings, most of them with clothing insufficient to cover them ; 
scarcely any of them with enough to protect them from the cold ; 
fed upon pretty good bread, potatoes, and an occasional piece of 
meat — in fact much better fed than the children of the Wiltshire 



[ SCROFULA. ] 



399 



agricultural labourer. Of these children nineteen presented mani- 
fest signs of scrofula, affecting the glandular system, the eyes or 
j the bones. 

I In our own country scrofula is far from being so prevalent as it 
j is in different parts of Europe ; but on the other hand we do not 
I enjoy that entire immunity from the disease which some have pre- 
I tended. In the negro population it is of not unfrequent occurrence, 
j But it would be an error to suppose that the attacks of scrofula are 
1 restricted to the children of the needy, and the destitute with insuf- 
| ficient food. We know that, in Europe and occasionally in this 
| country, we meet with it in persons very differently circumstanced ; 

and I remember well hearing Alibert, when lecturing on the subject, 
| at the Hospital St. Louis, ask, with a somewhat triumphant air — if 
poor and insufficient food and other sedative causes brought on 
| scrofula, and if it was of mere debility, how came it to be a dis- 
j ease so common among the well-fed English who ate beef-stake 
i and drank porter? The sons of George the Third were sufferers 
from this disease; and it was to hide the disfiguration produced by 
j scrofulous ulcers of the neck in the young princes, that the fashion 
I of large rolling cravats was introduced. 

After giving full weight to these exceptional cases, it is still, how- 
ever, pretty evident that that portion of a people who live congre- 
gated together in close narrow streets, and dark and illy ventilated 
and damp or underground apartments, and whose food is bad and 
scanty, and clothing not adequate to protect them against atmosphe- 
I rical vicissitudes, are the greatest sufferers from scrofula. Deficient 
ventilation and want of active bodily exercise in the open air are 
the causes which can be most insisted on. 

The physiognomical traits of scrofulous children of the white 
race are, great size of the head, tumefaction of the free borders of 
the eyelids, length of the eyelashes, flattening of the root of the 
nose, an excessive volume of the lips, and, in some, high and broad 
cheek bones-. Chaussier believed that the greater number of chil- 
dren disposed to scrofula have bad first teeth. There is also a 
tendency to eruptions or scurf on the scalp. The intellectual fa- 
: culties are often greatly and prematurely developed. Very com- 
monly in scrofulous persons we find a vicious conformation of the 
' chest ; the thorax is narrow and arched in front — pigeon or chicken 
breast, as it is termed ; the shoulders are raised, and the abdomen 
is large. In the greater number of patients threatened with scro- 
fula the digestive functions are irregularly performed, the appetite 
is depraved or lost ; there is frequently diarrhoea ; the skin is usually 
very white, fine, transparent, with the sub-cutaneous veins very 
apparent. The assertion that scrofulous patients have fair hair, 
' true in many cases, cannot be received as a general proposition, 
| since we meet with the larger number of the shades of dark than 
of light hair in the disease. 

Whilst we base the treatment of scrofula on the proposition con- 
tained in the concluding sentence of Dr. Stokes's lecture, viz., the 



400 



STOKES'S THEORY AND PRACTICE. 



use " of everything calculated to invigorate the system and add to 
the existing sum of vitality," we are not to carry it out in the vulgar 
sense, by the uninterrupted administration of nutritive and medi- 
cinal stimulants, without regard to the state of the digestion and to 
visceral complications. The system can never be invigorated un- 
less the stomach and bowels be fitted to discharge their chyliferous 
office. With this view it is necessary, in the disease before us, to 
act on them, at first, and occasionally at intervals in the subsequent 
treatment, by purgatives — compound powder of jalap, rhubarb and 
magnesia, senna and salts, sulphur water with a predominance in the 
first stage, of saline substances, and, in the second, of iron. By 
moderate purging in scrofula we quicken the digestive action and 
increase the activity of lacteal absorption in one direction, and that 
of lymphatic and interstitial absorption in another. We prepare 
also the way for tonics, so called, viz., vegetable bitters, quinine, and 
the preparations of iron, and the alteratives, such as iodine and the 
alkalies; the effects of which will be more sensible and salutary if 
laxatives be occasionally interspersed. 

But in order to render the above means at all available, we must 
enlist those other and antagonizing ones to the causes of the dis- 
ease. These are wholesome nutritive food supplied in a quantity 
short of oppressing the digestive system ; and country, at any rate, 
fresh and pure' air. If, in addition to these, we can obtain the ope- 
ration of active muscular exercise, we place the system of the patient 
under the sway of the genial and kindlier influences, by which health 
is at all times most surely preserved, and readily recovered when lost. 
M. Phillips believes " that by the well directed employment of strong 
muscular exercise, many cases of this disease, where even tumours 
are found in the neck, may be cured." 

Of the iodine, in the form of the hydriodate of potassa in solu- 
tion, and of a watery solution of the iodine through the medium of 
the salt just named, I can speak favourably from personal ex- 
perience. But I must add, that I have found this medicine more 
serviceable in bringing about a healing process of the scrofulous 
ulcers, than in preventing the tumours from becoming open ulcers. 
In some cases, indeed, J have succeeded in discussing the scrofulous 
tumours in the neck, which to all appearances would have ere long 
ended in ulceration. Commonly, I have directed the iodine and the 
hydriodate of potassa to be rubbed on the part in the form of oint- 
ment, at the same time that the w ? atery solution w r as taken inter- 
nally. The favourite preparation just now, for internal use, an'd 
the one which M. Phillips uses almost entirely, is the iodide of iron, 
the doses of which does not, he tells us, exceed in any case three 
grains three times a day. This gentleman has a register of 232 
cases, in which he has exhibited the iodide of iron. The minimum 
dose has been a grain twice a day, the maximum that just detailed. 
" Of these cases, only three times was it necessary to intermit the 
use of the medicines for a few days; in one of these it excited 
ptyalism ; it was laid aside for a fortnight, again resumed, and again 



[ SCROFULA. ] 



401 



produced ptyalism. Since that period, and within the last twelve 
j months, the same patient, on her return from Margate, has been 
taking the medicine with the most decidedly good effects, and with- 
j out pytalism." 

The writer just quoted makes an observation, in the accuracy of 
I which I fully concur, viz., the rapid change which follows the em- 
ployment of the iodine or the iodide externally, and which is mani- 
) fested in a striking diminution of the tumour: but after a fortnight 
j or three weeks the latter appears stationary. Then is the time to 
\ resort to a new form, which should be employed for a similar 
j period, and in its turn give place to a third. Mr. Phillips, also, as I 
j think, justly adds, that, without a concurrent internal administration 
. of some preparation of the medicine, the effects of external applica- 
' tion.s are much less decided. 

On the termination and mode of treating ulcerated scrofulous 
J tumours, the remarks of Mr. Phillips will be found practically valu- 
i able. He warns us, that in the cases in which scrofulous matter has 
been deposited in its cheese-like form, " neither iodine nor any other 
i remedy which we know, has power to procure its absorption ; when 
j it is deposited there it must remain; a point around which irritation 
| is easily kept up, and about which, sooner or later, suppuration will 
take place, the abscess will either break, or art will interpose to 
facilitate this result by puncture, and it may thus be eliminated from 
the system." In a large number of cases, in spite of the most 
prudent treatment, the local disease will end in abscess ; for instance, 
out of 89 cases, 33 presented this termination. It would, of course, 
I continues Mr. R, be desirable that not only the thin sero-purulent 
matter, which is usually contained in such abscesses, but also the 
scrofulous product should be evacuated before the thinning of the 
integuments has proceeded far and a violet colour is assumed. If 
the product have not undergone softening, often no evacuation of 
the matter will take place, but if it have, a slight oozing, bringing 
away from day to day small portions of this matter, will be the 
course of evacuation, and often many months will elapse before the 
gland and its contents shall have been evacuated, and at the end of 
that time an unsightly cicatrix will be the consequence. This re- 
sult is accomplished in the following way : one or two small 
openings in the thin violet-coloured integuments, are the channels 
through which the matter is discharged. A more or less extended 
cavity exists under, produced by the breaking down of the gland 
and its surrounding cellular tissue. When the whole of this struc- 
ture is broken down and evacuated, this surface presents granula- 
tions, which have a tendency to skin even without adhering at all, 
or on other occasions only partially, to the superjacent thinned inte- 
I guments. The consequence of this is an irregular puckered surface, 
j and when, as is often the case, the subjacent tissue becomes ad- 
! herent to the deeper-seated parts, the deformity is increased by a 
pitting. To prevent this aggravation, two modes may be resorted 
to. When the time for procuring the evacuation of such a tumour 

35 

I 



! 



402 



STOKES'S THEORY AND PRACTICE. 



has arrived — when the integuments have become much thinned — 
the best mode of opening it, is by applying the Vienna caustic paste 
to the part, taking care that the paste shall include the whole of the 
thinned structure. A fair and sufficient opening will be thus made ; 
the evacuation will be more speedy, the remaining tissues will be 
healthy, and the cicatrix will be comparatively trifling. If, how- 
ever, this have been neglected, or another course pursued — if the 
discharge be going on from one or more small points — if the inte- 
guments over the parts be very thin, then with scissors we should 
excise the whole of the violet integument, and we may then hope 
to lessen the deformity, which would otherwise succeed to the dis- 
ease. But much valuable time would probably be lost, in the en- 
deavour to heal the sinuses connected with the cavity ; the various 
forms of iodine, in a more or less concentrated state, would have 
been applied to them, and the patient subjected to much suffering. 
And, here, Mr. Phillips states, in conclusion, that after much experi- 
ence of such applications to these sinuses, he is decidedly of opinion 
that they occasion more pain and are much less efficacious than the 
nitrate of silver. 

Reference hitherto has been chiefly made to the local manifesta- 
tions of scrofula in the subcutaneous lymphatic glands. But other 
parts are also, though less seldom, the seat of this disease. Of these 
the sub-lingual and sub-maxillary glands have been mentioned ; the 
parotid more rarely, but a chronic swelling of this organ is occa- 
sionally, seen in scrofulous subjects of a dark complexion. Tume- 
faction of the tonsils is seldom absent when the strumous constitu- 
tion is strongly marked. It is of some importance for us to be 
aware of the appearance and organic changes of the tonsils in 
scrofulous subjects. These parts are so affected as to jut out in 
rounded tumours from between the arches of the fauces ; and they 
are peculiarly prone to inflammation, which, when it occurs, is 
often attended by so much swelling as to threaten suffocation, 
especially, when stimulant astringent gargles have been incau- 
tiously employed. The inflamed tonsils become speedily spotted 
with apthous crusts, which are succeeded by superficial ulcera- 
tions, always indolent, and sometimes ending in brown excavated 
ulcers, which have been known to exist for weeks without any 
remedy being used, and then yield to quinine or other preparation 
of cinchona. 

Scrofula occasionally attacks the tongue, the disease alternating 
with strumous eruptions, especially on the face, and exhibiting in 
its progress small knots or nodules superficially embedded in the 
substance of the organ, which are succeeded by sloughing ulcers 
with much pain, profuse salivation, furred tongue, and fetid breath. 
Under proper treatment these ulcers become clean, contract and 
heal ; but the hardness remains and smaller fresh ulcers form. 
The mucous membranes are frequently affected with scrofulous 
disease ; as well those on the inside of the lips and cheeks and on 
the fauces, as on the pituitary membrane, constituting in the last 



[ SCROFULA. ] 



403 



case one of the varieties of ozsena. The ultimate terminations of 
the respiratory mucous membrane are frequently the seat of scro- 
fula ; and by some eminent pathologists it has been alleged that 
the air vesicles of the lungs are the usual situations in which tuber- 
culous matter is originally deposited in cases of scrofulous phthisis. 
The digestive mucous membrane is subject through its whole 
extent to scrofulous disorder of function, and in its intestinal por- 
tion at least to extensive scrofulous transformations. Tubercles 
are met with in the walls of the intestinal tube in children, and 
still more frequently in adults. Louis states that in his examination 
of more than 350 phthisical subjects above the age of fifteen, he 
found tubercles in the small intestines of one-third, and in the large 
intestines of one-ninth of the whole. The subsidiary organs of 
digestion and assimilation also suffer from this disease, one proof of 
which is furnished in the cases of the liver, by chalky and various- 
coloured intestinal discharges. The irritation of the mucous coat 
of the intestine continued along the absorbents to the mesenteric 
glands in scrofulous subjects, is followed by tuberculous deposits in 
these organs and a train of symptoms indicating tabes mesenteric a , 
or mesenteric consumption. Farther details on the pathology and 
outlines of the treatment of that disease have been already presented 
by Dr. Stokes at the concluding part of the eighth lecture of the 
present series. 

Scrofulous disease of the mucous membrane of the genital 
organs, particularly in females, is obstinate and troublesome. One 
of the varieties of leucorrhoea is of this nature. The testicle is not 
unfrequently the seat of scrofulous tumour and degeneration. A 
similar remark may be made of the mamma. Scrofula of the 
mamma appears in different shapes, and in its earlier stages is not 
always distinguished from disease of a more formidable character. 
Sometimes a hard lump forms on the breast, and remains nearly 
quiescent for several years ; at others the whole gland is affected 
with scrofulous enlargement ; but in every case of the disease its 
tendency is to suppuration, and the purulent matter discharged is 
more or less mingled with curdy flakes: instances likewise occur 
in which large masses of tuberculous matter come away. In the 
progress of such cases the integuments become inflamed, assume a 
livid colour, and are extensively detached from the parts beneath ; 
new abscesses and apertures form, and the adipose and glandular 
tissues are traversed by many fistulous passages, while the conti- 
guous parts are condensed and hardened. In strumous disease of 
the breast, there is always an enlargement of the gland instead of 
that contraction which occurs in one form of carcinoma : the 
tumour is tender when squeezed, never possesses the stony hard- 

I ness which exists in the disease just named, and there is never, we 

j believe, retraction of the nipple. 

The tendency of the mucous membranes of the eye and lachry- 
mal passages to scrofulous disease is well knowm. Beer asserts 
that in Vienna nine-tenths of all the cases of ophthalmia in children 



404 



STOKES'S THEORY AND PRACTICE. 



are of a scrofulous character; and Benedict of Breslau estimates 
the proportion in that city as high as ninety-five in the hundred. 
With the variety termed ophthalmia palpebrarum vel tarsi, we are, 
also, familiar — the margins of the eyelids and the Meibomian fol- 
licles being the seat of the disease which causes vesicles and 
ulcerations in these parts. One of the most obstinate forms of 
scrofula, or rather a fixation of the disease, which it is most difficult 
to remove, is that seated in the lining membrane of the external 
auditory passage. It is usually marked by a profuse watery, then 
mucous, and at length purulent discharges, forming what may be 
termed strumous otorrhcea. Seldom does it disappear under a 
period of some duration and without injury to the sense of hearing. 
In cases of greater gravity the membrane of the tympanum 
becomes inflamed and is perforated, the small bones of the ear are 
discharged and irremediable deafness ensues ; or, perhaps, caries of 
the petrous portion of the temporal bone takes place, and the 
result is fatal. 

The occurrence of scrofulous inflammation of the synovial mem- 
branes of the joints, and the formation of what has been termed 
scrofulous pus, is of common occurrence in scrofulous subjects. In 
another affection of the joints, in which the characters of scrofula 
are unequivocally exhibited, the disease originates in the cancel- 
lous structure of the bones, which is found to contain deposits of 
tuberculous matter; and the cartilages and synovial membranes 
are affected secondarily by the spreading of the inflammation. 

It is sufficient to advert to the scrofulous changes in the bodies 
of the vertebras, as well as the intervening fibro-cartilaginous sub- 
stance, to recal to mind a form of exceedingly distressing disease, 
accompanied so often by deformity, — and passing under the general 
name of spinal curvature. As justly remarked by Dr. Cummin, to 
whose excellent summary in the Cyclopcedia of Practical Medi- 
cine I am now so largely indebted, it is not to be expected that the 
membranes of the spinal cord, the medullary substance itself, and 
the nerves which branch from it, should escape injury, when chronic 
inflammation has produced such extensive disorganization in the 
substance of the spinal column and the soft parts around. Accord- 
ingly, we find the first symptoms of caries of the spine are, a feeling 
of weight and aching in the part, itching and numbness, pains 
shooting round to the front of the trunk, and, when the disease is 
farther advanced, pains and twitchings of the limbs, succeeded by 
palsy of all the parts below the affected vertebras, and of the 
sphincters of the bladder and rectum. 

The serous membranes in different parts of the body, often exhibit 
decided marks of scrofulous disease, myriads of minute tubercles 
or tuberculous granulations being found adhering to their surfaces, 
or imbedded in their tissue, — and sometimes enveloped in the false 
membranes connecting them, which have formed during inflamma- 
tion. Thus the pleura, the arachnoid, the pia mater, the peritoneum, 
are frequently found affected with scrofula ; and a few instances 



[ SCROFULA. ] 



405 



are recorded where tubercles have been observed in the pericardium. 
When, continues Dr. Cummin, the disease attacks the membranes 
of the brain, its symptoms are usually those of acute hydrocepha- 
t lus ; and its termination takes place by effusion within the skull or 
spinal canal, to which is sometimes superadded softening of the 
! white or fibrous substance within. This kind of predisposition to 
| hydrocephalus has been already mentioned in my addition to 
Lecture XXVII., with the confirmatory experimental observations 
! of Drs. Gerhard and Rufz. 

The opinion, at one time general, of enlargement of the thyroid 
gland in bronchocele, being a scrofulous affection of this organ, is 
1 not sustained by careful inquiry and comparison. In districts, and 
i large manufacturing towns in England, in which it cuts off thou- 
sands in infancy, and scatters among the survivors the germ of 
debility and protracted disease, bronchocele is of rare occurrence. 
Allied to, though not identical with scrofula, is rickets, and en- 
cephaloid and medullary tumours. 

The greater sensitiveness of most scrofulous individuals, renders 
them more prone to diseases of the nervous class : hence an aggra- 
vated form of hysteria is more frequent in such persons ; and Dr. 
Cheyne thinks that epilepsy -affects strumous subjects oftener than 
others. The diseases of the mind claim an alliance with scrofula; 
and it has been alleged, on competent authority, that more than one- 
half of those who are subject to mental derangement are of a scro- 
fulous constitution, having some manifest indications of its existence 
in their persons. 

This sketch of the scrofulous modification of structural lesions of 
the tissues different from simple inflammation and its consequences, 
taken in connexion with the causes of scrofula, and the change 
which it produces in the organs of nutrition, will go far to suggest 
a suitable treatment. Inflammatory affections, in an especial man- 
ner, exhibit the effects of this influence, in their losing readily, if 
they ever displayed it, their acuteness of character, and becoming 
tardy and indolent, difficult of cure, and requiring for this purpose 
the use of stimulants and tonics. So strong is the modifying power 
of scrofula, or rather so readily do the organs take on the formation 
of a scrofulous product, that, as we learn from Dr. Cummin, the 
stump of a strumous girl's arm, which was removed on account of 
i extensive laceration, discharged curdy matter at the second dressing. 
I need not repeat the principles which must govern us in the 
treatment of scrofula, nor of the absolute necessity of placing the 
digestive system in a favourable state, to act on wholesome nutri- 
ment. Where inflammatory symptoms appear, we should not be 
deterred from the use of the customary means of depletion, because 
i the habit of the patient is scrofulous; but we must bear in mind the 
; ready tendency of the organs affected to form mixed products, and 
| that, although such formations may be presented at the outset by 
suitable depletion, yet when once in progress they will not be re- 
! moved by an antiphlogistic course. Thus a well timed, that is 

- alt 



406 



STOKES'S THEORY AND PRACTICE. 



early, venesection, will sometimes cut short a series of symptoms of 
inflammation of the respiratory mucous membrane as well as of the 
serous membranes of the head and abdomen, which, if neglected, 
would soon end in the formation of tubercles, although the same 
treatment would be of little avail in a more advanced stage of the 
disease, and would even be positively injurious. In the forming 
stage of scrofulous tumours, local depletion by leeches, or even of 
cups near the affected part, will often prevent their development, 
and the suppurative stage. 

It was once an established rule in the treatment of scrofula, or 
where we had to deal with disease in a manifestly scrofulous habit, 
never to administer mercury. That there were good grounds for 
this prejudice one cannot deny, but to carry it to the entire exclu- 
sion of an occasional mercurial purge, and even mercurial altera- 
tives, is going beyond the limits justified by experience. Thus, a 
purge of rhubarb and calomel will be useful to unload the bowels 
of accumulations which are so apt to form in strumous cases, and 
occasionally small doses of calomel, followed by rhubarb, magne- 
sia, or saline medicines, serve to promote proper secretions both 
from the liver and the mucous follicles of the intestines, and thus 
aid towards a restoration of healthy digestion. The real error and 
positive mischief consist in a protracted use of mercury, or in making 
the whole treatment turn on the employment of the prepara- 
tions of this metal, in place of regarding it as preparative for the 
true alterative course of fresh air, exercise, plain and nutritive food, 
bathing and friction, and the drinking of certain mineral waters. 
Failing soon to accomplish our purpose with mercurial alteratives, 
w r e must desist from their use, and rely on the means last mentioned, 
or have recourse to analogous agents of less equivocally secondary 
effects on the system. Of these iodine in various forms, as already 
indicated, is entitled to our confidence, alternately, or even combined 
with certain vegetable bitters and earthy salts. If we have been 
properly instructed by a knowledge of the modifications which 
scrofula impresses on the morbid changes of the organs, we shall 
have recourse earlier to iodine and other alterative stimulants and 
tonics than the persistence of some sub-acute inflammatory symp- 
toms might otherwise seem to justify. Of the class of tonics the 
sulphate of quinine merits the earliest and most frequent trials. 
There is a state, however, of parts accompanied with great pain, 
and some evidences of increased action of both the white and red 
vessels of a part, constituting mixed inflammation, which, though 
alleviated, is not cured by moderate depletion, and in which the use 
of tonics and stimulants is premature and injurious. In these cases, 
and they will include both scrofulous tumours of the neck and mam- 
mae, and of the mesenteric glands, as well as scrofulous enlarge- 
ments of the uterus, testicles, &c, much benefit, certainly ease, is 
procured by selections from the class of narcotics. Of these opium 
will, we must believe, ever hold the first place: next to it come 
conium or cicuta, hyosciamus, belladonna, and stramonium. In 



FEVER. 



407 



addition to the internal use of these latter, they are of service ex- 
ternally, in the form of ointments or plasters directly on the part. 
I have at times combined one of them, stramonium or belladonna, 
with mercurial ointment as a topical application, to be rubbed in or 
spread on muslin over the tumour. An old and favourite prepara- 
tion, the camphorated mercurial ointment, in cases of indolent 
scrofulous tumours and diseased joints, should still be regarded as 
entitled to confidence. — B.] 



LECTURE XXXVI. 

Fever — General considerations on — Erroneous modes of investigation — Importance of 
j the labours of French pathologists — complication of fever with local disease — Primary 
and secondary fevers — Relation of, to local changes— tendency to spontaneous termi- 
nation — Principles of treatment — Errors of Brown and Broussais — Researches of 
M M. Gaspard and Magendie — Their pathological conclusions — Importance of the 
knowledge of secondary lesions — Effect in preventing crisis — Treatment — Humoral- 
\ ism and solidism. 

It may be safely asserted, that, in the whole range of medical 
! science, there is no subject on which so much has been written and 
! so little known as fever. You will find, in the writings attributed 
to Hippocrates, a series of observations on the rise, progress and 
termination of febrile affections, which it must be acknowledged 
are characterized by singular beauty and truth; and I think I may 
venture to say, that such is their extreme accuracy, such the com- 
prehensiveness, acumen, and power of the master mind that made 
I them, that scarcely a single one has been overturned by the 
researches of modern times. From the period of Hippocrates almost 
down to the present day, the contributions to this department of 
medicines, though numerous and varied, were of very inconsiderable 
importance; they effected little towards the improvement of our 
knowledge of fever, and many of them were calculated rather to 
puzzle and mislead, than, to throw light upon what was difficult 
and obscure. In place of studying the phenomena and effects of 
fever, instead of applying themselves to what was tangible and 
j useful, the minds of medical men were occupied in tedious but 
' profitless attempts to discover the proximate cause of fever, and it 
was to this subject that the labours of some of the greatest men in 
medicine were exclusively directed for a series of years. The con- 
sequences of this was, that our knowledge made no real progress, 
and as little was known about fever in the time of Cullen and 
Brown as in that of Hippocrates. We had innumerable discussions 
as to its cause and nature, we had a vast quantity of learned 
writings and ingenious speculation, but they produced nothing avail- 
I able for practicable purposes, nothing tangible or real. The inves- 
j tigators failed, because they reversed the Baconian method of 
arriving at the truth; they first built up a theory, and then thought 
| to make the phenomena of nature square with it ; they forgot that, 
to be truly philosophical, we must first recollect, compare, and 



408 



STOKES'S THEORY AND PRACTICE. 



arrange facts ; and, when we have done this, we may deduce from 
them a theory, cautiously, and with a strict regard to truth. They 
did not pursue this course, and the consequence is that they added 
nothing to the sum of our valuable knowledge. Their disciples 
knew nothing more than was known to Hippocrates ; in fact, they 
knew less, for their notions on the subject of fever had reached 
them through an erroneous and distorted medium. The followers 
of Cullen viewed it through the theories of Cullen, the Brownists 
through those of Brown ; both alike forgot nature, and both were 
consequently inferior to Hippocrates in true knowledge. They 
attempted to discover the proximate cause of fever, and they failed, 
as men generally do, when they attempt to investigate first causes. 
We know very little, indeed nothing, of the nature of first causes ; 
they are, and will in all probability remain for ever, beyond the 
range of human intellect. It may be argued, that Cullen and Brown 
did not. seek to ascertain the first cause, but only the proximate 
cause of fever ; but this is only a play upon words, both are shroud- 
ed in the same obscurity, and in both the same difficulty attends 
our investigations. Even suppose we say with Cullen, that fever 
is a spasm of the extreme vessels ; or with Brown that it is asthenia 
of the whole system, what do we learn by this, or what use is 
our knowledge 1 Have we more defined and accurate notions of 
fever? — Certainly not. They failed, as all men do who occupy 
themselves in the fruitless labour of searching after first causes. 
There is but one First Cause, and even of Him we know nothing 
accurate, but what He has vouchsafed to reveal. 

Modern pathologists have pursued a course very different from 
this, and the consequence has been that they have arrived at the 
most splendid results. Instead of attempting to investigate proxi- 
mate causes, they have studied the phenomena and effects of fever, 
they have examined dead bodies, they have accurately appreciated 
the series of pathological changes they present, and endeavoured to 
connect those changes with the symptoms. In this great work the 
French pathologists took a prominent part ; indeed, I think it may 
be asserted, without fear of contradiction, that a vast proportion of 
our improved knowledge on the subject of fever is due to the 
French. It has been, I regret to say, too much the fashion to 
decry the labours of the French pathologists ; but I believe this has 
been chiefly done by persons who would gladly possess the know- 
ledge they affect to despise. The French pathologists have pur- 
sued with respect to fever the same method they have so success- 
fully employed in the investigation of other diseases ; and though 
their researches have not thrown any important light on its proxi- 
mate cause, they have taught us a vast deal as to its phenomena 
and complications, they have established a great number of valuable 
facts, and unfolded a series of beautiful truths ; and, I need not say, 
that it is in the appreciation of these facts that a proper knowledge 
of fever consists. 

In the first place, they have strongly drawn the attention of the 



FEVER. 



409 



j medical world to this great truth, which should be engraven on 
your minds — that mere fever, without local disease, is of very rare 
| occurrence. Here was a new and extraordinary light thrown upon 
the misty doctrines of the older pathologists. With them fever was 
I a nonentity, something they endeavoured to describe but could not, 
j something apart from, and totally unconnected with, organic change. 

The result of this mode of viewing the question was a variety of 
! crude hypotheses and fanciful speculations. Bear this always in 
| mind — mere fever, unaccompanied by local disease, is very rarely 
i met with. Recollect, too, that it has been established beyond the 
possibility of doubt, that fever, complicated with local disease, is the 
j rule, and its non-complication the exception. We have further 
j learned from modern pathology, that every system and every organ 
! in the body may be, and frequently is, diseased during the course of 
j fever, and that, in the vast majority of cases, death is the result of 
| one or many local inflammations. We further learn, that the cha- 
' racter and symptoms of fever are infinitely varied, and that the 
cause of this variation mainly depends on the seat, the number, and 
j the nature of the local affections. It is to these that we are to at- 
' tribute the principal modifications in the character and phenomena 
! of fever, and it is by these that its course and termination are 
mainly influenced. 

Dr. Fordyce, in his work on fever, attempts to give a definition 
of the disease, and as I feel convinced that it is, if not a definition, 
at least one of the best descriptions of fever, I shall give it as nearly 
as possible in his own words. The style of this description is quaint 
! but expressive. "Fever," says he, " is a disease which affects the 
whole system ; it affects the head, trunk, and extremities; it affects 
the circulation, absorption, and the nervous system ; it affects the 
skin, fibres, muscles, and membranes; it affects the body, and it 
affects the mind ; it is, therefore, a disease of the whole system in 
the fullest sense of the term. It does not, however" says he, " affect 
the various parts of the system uniformly and equally, but, on the 
contrary, sometimes one part is more affected than another" This 
last observation is totally at variance with the idea that fever is a 
mere morbid condition of the whole system without reference to 
local lesions, for he expressly states that it does not affect the whole 
system uniformly and equally. This excellent view of fever seems 
to be borne out completely by modern pathology, and particularly 
the last part, where he says, that in cases of fever one part is more 
affected than another. We have, for instance, cerebral fevers, 
nervous, bilious, gastric, and catarrhal fevers, by which, it is to be 
observed, we do not mean to imply that there is nothing more than 
j simple disease of the brain, or nerves, or liver, or bowels, or respi- 
! ratory system, but that in each of these fevers, disease predominates 
I in some particular part. So that when we speak of these fevers, 
i we speak of such a disease as Fordyce has described, in which one 
part of the body is affected more than the rest. In many of the 
schools you will still meet with Cullen's division into synocha, 
i ' , 



410 STOKES'S THEORY AND PRACTICE. 

synochus, and typhus, a division by which we gain nothing at all, 
these terms being but mere words and no more. Will any one 
define what is meant by synocha, or synochus 1 Will any one say 
what is typhus'? Will anyone say that a particular class and 
character of symptoms and morbid changes apply to any of these 
affections ? It would be quite impossible. What we generally find 
is, that in the different cases of what have been termed synocha, 
synochus, and typhus, though they may present the symptoms be- 
longing to each separately, yet in these same cases, at some period 
or other, the symptoms pass into one another so as to confound the 
original distinction. We have synocha to-day, synochus to-mor- 
row, and then typhus; or we may have typhoid symptoms at first, 
and inflammatory ones afterwards, and so on. We find, too, that 
similar causes will produce in different individuals essentially dif- 
ferent forms of fever, and hence it is that we cannot found any dis- 
tinction of fevers on their exciting causes. Nothing is more com- 
mon than to see in two patients the same lesion producing, in one 
the synocha, in the other the typhus of Cullen. Thus, whether we 
look to the progress, symptoms, or exciting causes of fever, we find 
that this division has no foundation in nature, and is purely scho- 
lastic* Synocha, synochus, and typhus, are but mere names 
without meaning, terms which belong to the dogmatism of theory, 
and not to the expression of truth, and yet it is dreadful to think of 
the numerous lives which have been sacrificed at the shrine of this 
dogmatism. 

Fevers may be divided into two classes. We have, in the first 
place, fevers which we may call primary or essential, in which we 
find (as far as human investigation can go) affection of the whole 
system, of the fluids as well as of the solids. This general state of 
the whole system seems in such fevers to have the initiative, con- 
stituting the first step in the process of disease; but it is also true, 
that, in almost every instance of essential fever, local disease springs 
up at some period or other of its course. We have, then, in these 
fevers this primary state of the system, the cause and nature of 
which are unknown, and we have this followed by various se- 
condary lesions, affecting different parts of the body, and presenting 
characters by which we can arrive at a knowledge of their nature, 
more or less. 

In the second class of fevers, we place all those in which the 
first affection is local, and the fever secondary. Observe the dis- 
tinction between this and the former class. In the first kind, or 
primary, the local disease is consequent on the fever, in the 
secondary, fever is the result of local disease. Let us take an 
example of each. A person- in health is exposed to the contagion 
of typhus ; he becomes languid and weak, has troubled sleep, bad 

* [This important truth, so long familiar to the profession in the United States, 
through the writings and lectures of Dr. Benjamin Rush, is not yet fully admitted 
and appreciated by the European schools of medicine.— B.] 



FEVER. 



411 



digestion, and low spirits ; after some time, what is called fever 
sets in, and during the course of this, various local diseases may 
supervene. In the other case, a person, also in health, from 
exposure to cold, or from some local injury, gets an attack of 
inflammation of the lungs, or some other local lesion, and, as a 
consequence of that lesion, has symptomatic fever. 

Now the relation which the fever bears to the local symptoms in 
each of these cases is different. In the first case, the fever is pri- 
mary, and the local affections secondary; and it may happen that, 
although the local diseases may be modified or removed, the fever 
will still continue ; but in the second, the fever always vanishes on 
the removal of the local disease. We have to enter on the con- 
sideration of the first of these to-day, and to examine that morbid 
stale of the whole system in which local disease supervenes at 
some period of the fever ; in other words, where the lesions of par- 
ticular parts or organs are symptomatic of the fever. 

I have already mentioned, that one of the great truths at which 
modern pathologists have arrived is, that local disease commonly 
occurs during the course of fevers. It has also been established 
that, in the great majority of cases, the cause of death is one or 
more local inflammations. The experience of every candid patho- 
logist is in favour of this doctrine. Patients seem to die of fever, 
but the fact is that some die by the brain, some by the lungs, others 
by the digestive system, that is to say, during the course of fever 
they get disease of various organs, some of the brain, some of the 
lung, and a vast number of the digestive system, often sufficient to 
destroy life if there was no fever at all. It is an undeniable fact, 
that, in the great majority of cases, there is local disease of some 
part or other of the body, and that a vast proportion of fever 
patients are carried off by local inflammation. How plain then is 
the deduction from these facts, that the man who neglects the 
viscera in fever is practising with his eyes shut. 

So much for the first great fact of the complication of fever with 
local disease, and its important bearing on practical medicine. 
But there is another general consideration with respect to these 
primary fevers, they have a tendency to terminate spontaneously; 
of the cause of this spontaneous termination we are still in igno- 
! ranee. One of the most simple and familiar examples of this is the 
I paroxysm of an intermittent. A patient, who is at present appa- 
! rently in good health, will in the space of an hour or less be 
I attacked with severe rigors, followed by all the symptoms of 
| fever, a flushed countenance, hot skin, quick pulse, and high 
I coloured urine, and in some time afterwards a copious perspiration 
I breaks out, which is attended with complete relief to the symptoms, 
j and the patient gets well again. From this time until the period 
I of the next attack he continues to all appearance in health. Now, 
i if we consider each of these paroxysms as an attack of fever, we 
| see in them an evident disposition to terminate spontaneously. The 
| same thing occurs in the case of the exanthemata. Scarlatina, 



412 



STOKES'S THEORY AND PRACTICE. 



measles, and small-pox, have a regular course, which generally 
terminates at stated periods ; they also exhibit a succession of 
stages characterized by corresponding symptoms. We observe 
the same disposition to terminate spontaneously in most continued 
fevers, and it has been further remarked, that this spontaneous ter- 
mination generally occurs on particular days. We have then two 
great leading facts in the history of all primary fevers, first, that 
they are most commonly complicated with local disease, and, in 
the next place, that they have a great tendency to terminate spon- 
taneously and on particular days. 

Now, gentlemen, you will please to observe, that a knowledge 
of these two very important facts furnishes us with two great indi- 
cations—one, to discover and remove, or modify the local inflam- 
mations ; the other, to support the patient's strength, so that he 
may not become exhausted during the progress of the disease, and 
thus lose his chance of this spontaneous favourable termination. 
These two indications, though apparently incompatible, are not so 
in reality. You will of course understand that the extent to which 
we pursue one or other of these indications, must necessarily vary 
according to circumstances. The rapidity, violence, and particular 
seat of the local inflammation, the duration of the attack, the age, 
sex, and constitution of the individual, all these are circumstances 
which must be taken into account in adopting any plan of treat- 
ment, whether calculated to remove local disease, or support the 
patient's strength. 

The similarity between the different individual cases of fever, is 
too faintly shadowed out to amount to anything like identity; in 
fact, there are no two cases of fever perfectly alike. You might 
as well expect to find two human beings exactly alike as to find 
two cases of fever perfectly similar. The causes of this remarka- 
ble variation are reducible to the extent, variety, seat, and compli- 
cation of local disease, and to the peculiarities of the patient's con- 
stitution. These two classes of circumstances produce infinite 
varieties in the appearance and character of fevers. 

The followers of Brown saw nothing in fever but debility, and 
their practice was to support the strength, and give stimulants from 
the commencement, ignorant of the fact, that neglected local in- 
flammation will produce and keep up debility. The followers of M. 
Broussais, on the other hand, think that fever is sympathetic, that 
it depends on local inflammation, and that it must be subdued by 
depletion. Truth lies between. We must do both, we must com- 
bat the local inflammations by antiphlogistic means, and we must 
support the patient's strength by a well regulated regimen. These 
two indications are by no means incompatible, but their application 
must vary according to circumstances. If it be true, then, that 
local disease is very common in fever, and a frequent cause of 
death, it is plain that to practise without a knowledge of the state 
of the viscera, would be acting like the physician mentioned by 
D'Alembert. He compares him to a blind man armed with a 



FEVER. 



413 



club, who comes to interfere between nature and disease. If he 
strikes the disease, he kills the disease ; if he strikes nature, he kills 
nature. 

A discussion has arisen in modern times, as to whether we 
should look upon all fevers as sympathetic. This is one of the 
leading doctrines of the school of M. Broussais. He declares that 
all fevers are sympathetic, that there is no such thing as an essential 
fever, or, in other words, that there never exists that peculiar mor- 
bid state of the whole system to which we apply the term fever ; 
that in all cases fever is the result of local lesions, and that on the 
removal of these lesions its cure will depend. To this conclusion 
the school of M. Broussais was compelled to come in consequence 
of their exclusive solidism. They endeavour to reduce all the phe- 
nomena of life, whether in a state of health or disease, to the mutual 
action and influence of the viscera and solid parts on each other. 
They are solidists, in the strict sense of the word, and can have no 
conception of fever as existing independently of some primary 
local lesion. But it seems that the leading points of this doctrine 
have not been able to stand the test of an impartial examination, 
and may at present be looked upon as disproved. You will see 
at once the importance of this, when you consider that if it be true 
that all fevers are sympathetic, the practice must necessarily consist 
in the discovery and removal of local lesions, and no more. But I 
said that these doctrines are now disproved, and the following 
arguments may be laid before you in proof of this statement. 

In the first place, let us inquire whether any cause acting on the 
whole economy is capable of producing local disease. Mark, the 
object of our inquiry is to ascertain whether any cause operating 
on the whole economy is capable of producing local disease. Now, 
I believe it is quite certain that such is the fact, and that we may 
have, first, a morbid condition of the whole system, and, consequent 
on this, various local lesions. Several continental pathologists, but 
in particular MM. Gaspard and Magendie, have shown, by repeated 
experiments, that we can produce all the phenomena of typhus in 
the lower animals, by introducing putrid substances into the system. 
These gentlemen injected putrid substances into the veins of ani- 
mals, and applied them to the surfaces of wounds, and, in every 
case where these experiments were performed, they observed that 
the animals became ill, had languor, loss of appetite, thirst, prostra- 
tion — in fact, all the symptoms of bad typhus; and, in case of 
death, that they exhibited, on dissection, local lesions correspond- 
ing with those we meet with in the human subject in fever. 
Now, observe, these animals were, previous to the experiment, in 
a state of perfect health ; they are, then, subjected to the operation 
of a cause which is found to produce a morbid state of the whole 
system ; they die, and on dissection inflammation and ulceration of 
the mucous membrane of the digestive tube, and other lesions, are 
discovered in almost every instance. It would be quite absurd to 
say here, that the ulceration of the bowels was the cause of the 

36 



414 



STOKES'S THEORY AND PRACTICE. 



morbid symptoms, for the animals were previously healthy. We 
can come to no conclusion, then, but that the introduction of putrid 
matter produced that morbid state of the whole system which is 
termed fever, and that the local inflammation was the result of this 
state, ll is the same thing with respect to the exanthemata. A 
child is exposed to the contagion of small-pox ; for some time no- 
thing particular is observed ; he then get sill and feverish, and this is 
followed by an eruption of variolous pustules. Here we have a 
local disease consequent upon a circumstance affecting the whole 
system, and in this, as in the former examples, the local lesion is 
secondary. We might as well argue that the pustules were the 
cause of the symptoms in one case, as to say that the ulceration of 
the intestines was the cause of the other. Every one, I think, will 
admit that the pustular eruption in a case of smail-poxis secondary, 
and not the cause of the symptoms; and the same argument will 
apply to the secondary affections of typhus. If it be true, as ap- 
pears by M. Magendie's cases, that fever follows the introduction 
of putrid substances into the body, and that this morbid state of the 
system produces inflammation of the intestinal mucous membrane; 
if, too, we admit that in small-pox the pustules are secondary, and 
consequent on a morbid state of the whole system originating in 
contagion, the same argument will hold good in all cases of local 
inflammation, (whether of the liver, lungs, brain, or any other 
organ,) which may arise during the progress of fever. These facts 
are adduced in support of the first part of the argument — that local 
lesions maybe and are consequent on that morbid state of the whole 
system to which the name of fever is applied. 

The next thing to be observed with reference to this question is, 
that if it be true that typhus is merely symptomatic of local disease, 
it would then follow that there should be as constant a relation 
between the symptoms during life and the morbid changes seen 
on dissection, as there is between the fever of pneumonia and the 
changes presented by the lung. But this is not at all the case, for 
we find that there is no constancy, no uniformity, either in the seat 
or extent of the local disease. Two patients will exhibit symptoms 
of typhus not differing in any material point, and yet, on dissection, 
you will find little or no traces of disease in the intestinal canal of 
one ; in the other, you will find in the same parts a vast amount of 
disease. Two others will also present symptoms very similar; in 
the one you will find the lung healthy and normal, in the other, 
you will find it extensively disorganized. Would it not be absurd 
to assert here, that the fever was symptomatic of the local lesion, 
seeing that there is no constant relation between the symptoms and 
the morbid changes, either as to situation or extent ? Again ; it is 
a fact, that you may have several patients presenting different symp- 
toms, and yet, when you come to examine their bodies, you find 
the same morbid changes in alL One may exhibit all the pheno- 
mena of typhus ; in another, this condition is but slightly marked ; 
in a third, it is absent ; and yet, on dissection, you find a similarity 



FEVER. 



415 



of local lesion. Lastly, it may be argued that if typhus were symp- 
j tomatic of any particular local lesion, we should be able to cure it by 
; removing that local lesion. This, however, is not always the case ; 
that it sometimes does occur I am willing to admit, and this is there- 
fore to be considered as the weakest of my arguments. But, on the 
I other hand, if it be admitted that the local lesions are accidental and 
secondary, we can easily understand why their removal should not 
! necessarily cause the removal of the fever. Such are the arguments 
j on which I ground my objections to the doctrine — that all fevers are 
I merely symptomatic of local disease ; and in these views I think I 
i am borne out by the opinions of the soundest modern pathologists. 

But though we admit that local inflammations are secondary, 
I and bear the same relation to typhus as the eruption of small-pox 
to the morbid state that precedes it, still they are not the less 
i important; and it is by a careful study of them that we arrive at a 
! key to correct and successful treatment. They are of great import- 
! ance from being exceedingly common in fever; in fact, so common 
that their occurrence is the rule, their absence the exception. 
; They are also, in the majority of cases, the cause of death, and this 
they bring about in two different ways. First, directly, as in a case 
of simple inflammation. A patient in fever, who gets an attack of 
violent enteritis, may die of it as well as if he got an attack of pri- 
mary enteritis ; or he may die of pneumonia coming on during the 
course of his fever as well as the man who dies of pneumonia from 
cold. Thus we see that the secondary inflammations may produce 
death directly. They may also produce it indirectly, by preventing 
! the efforts of nature towards a favourable termination. You recol- 
lect I told you, that in fevers there is a strong tendency to termi- 
nate spontaneously and on particular days. Now we find that this 
disposition is greatly impeded by the presence of local inflammation, 
so that local inflammation may operate to the destruction of life in 
two ways; either directly, by its intensity and extent, or indirectly, 
by preventing a critical termination. 

This leads us to look still deeper into the matter. We find that 
these local or secondary affections may also produce a train of 
sympathetic phenomena of a very remarkable character. There 
is no reason why enteritis coming on during the course of a fever 
may not react on the economy as well as the enteritis from cold, 
i which we know generally produces symptomatic fever. In the 
case of two patients, one, for instance, meets with some lesion of 
the intestinal mucous membrane, and, as a consequence, gets en- 
teritis and sympathetic fever ; another gets enteritis during the 
course of a typhus; in the one case, the local lesion plainly reacts 
on the system, in the other this is less apparent, but there is no 
reason to suppose that it does not produce some effect on the system 
in one case as well as in the other. The law appears to be this, that 
in almost all cases of fever there is a combination of the essential 
and the sympathetic fevers, the essential the result of the first cause, 
and the sympathetic the result of the local lesions which arise 



416 



STOKES'S THEORY AND PRACTICE. 



during its course. Indeed, nothing seems to be better established 
than that local disease reacts on the system and prevents a critical 
termination. You will get a very good idea of this by considering 
the paroxysms of an intermittent. What are the periods in which 
an intermittent is most liable to terminate favourably ? The earlier 
ones. What are the periods in which a favourable termination is 
least likely to happen ? The later ones. Now what are the periods 
in which there is little or no accompanying organic lesion ? The 
first or earlier. What are those in which there is more or less of 
organic change ? The later, in which we generally find, on making 
a careful examination, that disease of some organ, or organs, has 
taken place, and is presenting an obstacle to a favourable termi- 
nation, it is the same thing with respect to fever. 

In the treatment of fever, it is a most important rule to investi- 
gate the condition of the viscera, and remove, if possible, any exist- 
ing local inflammation. By this we accomplish a double purpose ; 
we prevent the direct danger of death from the violence of local 
disease, and we obviate the inconveniences arising from sympa- 
thetic irritation. We give nature fair play, we reduce the case to 
a state of the greatest simplicity, we prevent the liability to new 
local affections, and we thus effect a great deal towards a favour- 
able termination. It is an interesting and singular fact, and one 
dwelt on by the school of Broussais, that in many cases of fever 
the removal of the local inflammations is speedily followed by a 
subsidence of the fever. It is chiefly from this fact that they argue 
in favour of the opinion, that all fevers are symptomatic of local 
disease. This argument, however, as I have already proved, is 
more specious than solid. The true reason is, that by removing 
local disease we remove the barrier which opposes the salutary ope- 
rations of nature. Every attempt at a favourable termination is 
impeded by the coexistence of local disease, and the more intense 
and extensive this is, the greater is the obstruction. You are not 
by any means to conclude that a fever is symptomatic, because it 
disappears on the removal of local disease; the true explanation 
is, that by subduing the local inflammation you have removed 
a focus of irritation, and given scope to the preservative powers of 
nature. 

These I believe most firmly to be the true principles which 
should guide us in considering the subject of fever. They have 
been obtained by careful and accurate deduction, and are based on 
a numerous series of well conducted experiments. Weigh the 
matter calmly, and I think you will be disposed to agree with me, 
that fever in its origin implies no tangible condition of the system, 
and that we know it only as consisting of a group of phenomena, 
varying as to their cause, seat, effect, and duration. The humor- 
alists erred by fixing its seat in the fluids, the solidists by limiting 
its locality to the solids. We recognise no distinction between the 
fluids and solids, so far as fever is concerned ; they all form parts 
of the great whole ; one cannot act without the other, but their 



INTERMITTENT FEVER. 



417 



mutual reaction is extensive and various. From these considera- 
tions we deduce the important rule, that there is no mode of treat- 
ment universally applicable, and the man who treats fever with 
wine and stimulants only, or he who contents himself with purga- 
tives and diaphoretics, or he who limits his practice to leeches and 
the lancet, that man knows nothing of fever. Though his hair be 
gray and his authority high, he is but a child in knowledge, and 
his reputation an error. On a level with the child so far as a 
correct appreciation of the great truths of medicine is concerned, 
he is very different in other respects ; his powers of doing mischief 
are greater, he is far more dangerous. Oh ! that men would stoop 
to learn, or at least cease to destroy ! 



LECTURE XXXVII. 

Intermittent fever — Definition and character of — Phenomena of the paroxysm — Cold 
stage — Internal congestions — Pathology of — Hot stage- — Ague not a simple fever — 
Affections of various viscera — Theory of Broussais— Effects of bark, quinine, &c. — 
Modus operandi of. 

To-day we commence the consideration of intermittent fever. 
One of the most prominent characters of this affection is expressed 
by its name; we have all the phenomena of fever making their 
appearance at certain periods, and then disappearing, leaving an 
interval in which the constitution seems to be in the normal state, 
and continues so until the supervention of a second attack. It has 
been also termed a primitive or essential fever, in which there is 
no original local disease, and where the fever, in the beginning, is 
not symptomatic of any local lesion. We may define intermittent 
fever as a primitive, or essential fever, composed of many paroxysms 
which recur at certain periods, and in the intervals between which 
we have a state of apyrexia, or freedom from fever. This defini- 
tion, though applying to the great majority of cases, is still to a 
certain degree imperfect, for we meet w'ith examples of this disease 
in which the periods of attack are by no means regular or certain, 
and the state of apyrexia between the paroxyms not well marked. 
Thus, in two cases of intermittent, we observe that in one the 
patient appears, during the interval, to be completely free from 
fever, while in the other we find that the febrile symptoms continue 
to a certain extent after the subsidence of the paroxysm. As a 
general definition, however, the foregoing is tolerably good, and 
will be quite sufficient for practical purposes. 

Another remark to be made on this subject is, that an inter- 
mittent is not necessarily an essential fever. We may have it from 
lesions of various kinds. You are all familiar with that form 
which attends bad cases of stricture and retention of urine, and 
which has been called urinary fever. Here we have fever of an 
intermittent character, not essential, but depending upon a local 

36* 



418 



STOKES'S THEORY AND PRACTICE. 



lesion. We have many other instances of a similar kind, and I 
could easily multiply examples. 

I shall not take up your time by entering into a description of 
the various divisions of intermittent fever ; it is a species of know- 
ledge unconnected with any point of great practical importance, 
nor does an acquaintance with the nature of the disease, so far as 
frequency of paroxysm is concerned, shed any useful light on its 
treatment. The same principles of treatment are applicable to 
quotidian, tertian, quartan, and every other variety of intermittent. 
Besides, we know nothing whatever of the nature of an intermit- 
tent. We are here as much in the dark as we are in the case of 
continued fever. We are still in complete ignorance as to the 
cause of the periodicity which is so remarkable a feature of this as 
well as of other diseases. It is enough for us, in the present state 
of medical science, to know that such things exist, and, leaving the 
researches after the cause of the disease and its periodicity to future 
investigations, let us study the effects of the disease, and direct our 
attention to things within our reach. 

Let us, as far as we can, examine what takes place during the 
paroxysm of an intermittent. I think it my duty, as a lecturer on 
practical medicine, to direct your attention to this point rather than 
to the history of intermittents ; this is, I grant, not devoid of inte- 
rest, but it is a subject on which you will find ample information 
in the various systematic treatises on medicine. My intention is to 
endeavour to point out the true principles of treatment ; I shall, 
therefore, enter no farther into the history of intermittents than 
what is connected with diagnosis. This will certainly diminish 
the interest of a lecture on intermittent fever, but this cannot be 
helped ; it would, in a limited course of lectures like this, be quite 
out of my power to lay before you the mass of curious and instruc- 
tive matter connected with the history of intermittents. The 
paroxysm of an intermittent fever has been divided into three 
stages — the cold, the hot, and the sweating : but it simplifies the 
matter very much, to consider it as divisible into two stages, the 
sweating being the result of the hot stage. With respect to the 
cold stage, I shall endeavour to establish three great propositions. 
In the first place, it appears (and this is highly important) that, in 
the majority of cases (I do not say in all, for there is no general 
rule in medicine), there is, during the cold stage, a perceptible 
lesion of one or more internal organs, and that there is congestion 
of many, if not of all, the viscera of the three great cavities. To 
use a modern phrase, we have, during the cold stage of an ague, a 
state of hypersemia of the internal and anasmia of the external 
parts, or, in other words, the balance of the circulation is lost, the 
blood forsakes the surface and accumulates in deep-seated organs. 
The next proposition is, that this hyperemia, from frequency of 
repetition, or excessive violence, may be accompanied by, or pro- 
ductive of, an inflammatory condition of these organs. Lastly, that 
organs thus altered may in themselves become sources of irritation, 



INTERMITTENT FEVER. 



419 



react on the system, and powerfully tend to keep up disease. You 
see, then, that, in considering the phenomena of intermittent fever, 
we must follow the same road as in continued fever, and regulate 
our inquiries more in relation to the effects than the cause of the 
disease. 

The first of these propositions — that during the cold stage of an 
ague there is a congested state of almost all the viscera — is proved 
in every way that a pathological proposition can be proved. It is 
confirmed by an examination of the symptoms, by the results of 
treatment, and by the appearances seen on dissection. In this 
country, we very seldom have an opportunity of examining the 
bodies of patients who have died in the cold stage, for the intermit- 
tents of this country are trifling in comparison with those which 
are observed in warm climates. But the fact is fully borne out by 
an examination of those who have died in this country under such 
circumstances, as well as by the more numerous examples occur- 
ring in countries in warmer latitudes. Let us take the different 
parts of the system during the cold stage, and see how far the 
symptoms point out an accumulation of blood. First, let us 
review the nervous system. There is a feeling of tension and ful- 
ness about the head, the patient complains more or less of head- 
ache, the sensibility is diminished, and there is frequently stupor 
and coma, and in violent cases there may be convulsions. All 
these circumstances are indicative of congestion of the brain ; and 
accordingly we find, where we have an opportunity of making an 
examination, that the venous system of the brain is in a state of 
engorgement. In some cases, the carotids and their branches have 
been observed full of dark-coloured blood, the congestion of the 
lungs having interfered with the process of aeration. In the inter- 
mittents of warm climates still more remarkable effects have been 
witnessed — enormous congestion of the vessels of the brain, and 
frequently effusions of blood into its substance ; so that the symp- 
toms during life, and the appearances seen after death, tend to con- 
firm the fact of congestion, so far as the brain is concerned. If w r e 
turn to the pulmonary system, we find that nothing is of more 
common occurrence, during the cold stage of an ague, than lividity 
of face, anxiety, cough, and hurried breathing ; and when we come 
to examine the chest, we find, more or less dulness of sound on 
percussion, and the other physical signs of congestion of the lung. 
This is further confirmed by dissection ; the lung is congested, and 
of a dark red colour; it will often sink in water, and presents a 
condition closely bordering on hepatisation. If you examine the 
heart, you will find that its action is oppressed, the pulse is small 
and irregular, and the right ventricle, with the vessels attached to 
it, are found engorged. Proceeding to the abdominal cavity, we 
find the same indications of congestion. There is a sense of pain 
and fulness in different parts of it; the patient has vomiting, often 
diarrhoea, and a copious discharge of urine ; all this shows a 
violent determination of blood. You have often heard of the tume- 



420 



STOKES'S THEORY AND PRACTICE. 



faction of the spleen which accompanies the cold stage of an inter- 
mittent. Now, so rapidly does this occur, and so extensive is the 
engorgement, in many instances, that shortly after an attack we 
can readily feel and trace it distinctly. On dissection, we meet 
with abundant proofs of congestion ; we find the liver highly 
engorged, the intestinal mucous membrane very vascular, the 
mesenteric and portal veins filled with blood, the kidneys con- 
gested, and the spleen enlarged. Cases of rupture of the spleen, 
from excessive congestion during the cold stage of ague, and of 
hepatic apoplexy from the same cause, are described by Bailly. 
These facts are sufficient to prove the truth of the first proposition 
— that, during the cold stage of an intermittent, most of the internal 
organs are in a state of congestion. We are led to suspect this 
from the symptoms, and our conjectures are confirmed by dissec- 
tion. Indeed the most superficial observer must be struck with 
the remarkable retreat of blood from the superficial parts of the 
body. The skin is pale and shriveled, the bulk of the limbs 
diminished, the countenance collapsed, the whole surface cold, and 
superficial vascular tumours are observed to lose their vascularity 
and become reduced in size. All these circumstances lead us to 
the supposition of internal congestion, and this is corroborated by 
the results of dissection, which show the various internal organs 
in a state of hypersemia, and shows the retreat of the blood from the 
surface, and its accumulation in deep-seated parts. 

The next proposition is equally important — that the frequent 
repitition, or excessive amount of these internal congestions, may, 
and does, give rise to an inflammatory condition of the affected 
organs ; in other words, that the hyperaemic condition of certain 
viscera, during the cold stage of ague, and their subsequent organic 
lesions, stand in the relation of cause and effect. We find that the 
effect produced by the cold stage on the viscera is twofold ; we 
may either have congestion independent of any organic change, or 
we may have inflammation. In some cases, particularly in those 
w r hich occur in warm countries, the congestion is followed by 
violent inflammation ; in others, as in the cases of this country, we 
have chronic inflammation produced. But whether w 7 e meet with 
one or the other, whether the inflammation be acute or chronic, we 
find that, as soon as the viscera become affected in this way, a state 
of constitution is brought on in which the power of the usual 
remedies is diminished, and their use frequently prejudicial. New 
local inflammations are set up in various organs, and these, which 
were in the beginning only the effect of the disease, become, by 
reacting on the system, the cause of its continuance. In warm 
climates, where the congestion is excessive, there is nothing more 
common than to see fatal pneumonia, or violent gastritis, or rupture 
of the spleen, or cerebritis, supervening on a bad attack of ague. 
Strictly speaking, the production of inflammation in organs seems 
to belong more to the hot than the cold fit, and this we can easily 
understand. In the cold stage, the viscera are in a state of intense 



INTERMITTENT FEVER. 



421 



congestion ; violent reaction then comes on with the hot fits ; and 
when we have in any organ a stasis of blood, and violent action of 
its vessels, occurring during the existence of this stasis, it is not 
I surprising that inflammation should be the result. 

In the hot fit, all the phenomena, which we have been just now 
I examining, are reversed. Everything indicates that the energy of 
the circulation is about being restored, and that there is a powerful 
! determination to the surface. The pulse gradually rises in strength, 
I the rigors gradually disappear; the skin, which was cold and 
j shriveled, becomes hot arid tense; the face, which was blanched 
I and collapsed, assumes a full and flushed appearance; the cough 
I and hurried respiration are relieved ; the vomiting, diarrhoea, and 
, discharge of urine, cease ; and the stupor is removed. The vessels 
on the surface of the body become more and more distinct ; and in 
those who have large superficial veins, those vessels (though there 
was no appearance of them during the cold fit) stand out in bold 
relief like so many thick chords. I have alluded before to the 
greater severity of the cold fit of the intermittents of warm coun- 
tries ; the hot fit exhibits a corresponding degree of intensity. The 
cold fit is generally accompanied by violent vomiting and purging, 
! spasms and convulsions ; the hot stage is attended with fits resem- 
bling apoplexy, and is frequently succeeded by intense pneumonia, 
cerebritis, and other forms of visceral inflammation. Such occur- 
rences are rarely seen in the fevers of this country. 

The great principle to be borne in mind with respect to intermit- 
I tent fever is, that during the cold stage the viscera are in a state 
! of congestion, and consequently fitted for the reception of disease. 
When the hot fit comes on, this state of congestion generally dis- 
appears ; but if it should continue, we shall have a chance of 
inflammatory action being set up in one or more viscera, and in 
this way we may have a number of points of irritation in the 
system, complicating the original affection, and tending to retard 
the operations of nature and art towards a favourable termination. 
You can easily understand, that if the lung, which has been in a 
highly congested state during the cold stage, does not, during the 
succeeding hot stage, throw" off the load of blood completely, it 
will be less able to accomplish this at the next attack, and so on, 
until at length the process of inflammatory alteration is firmly 
established. The same observation applies to the other viscera. 
In some cases, just as in continued fever, we have the brain chiefly 
engaged, in others the lung, in others the digestive system; and, 
in the intense agues of tropical climates, we often have the three 
great cavities simultaneously attacked. You will observe here, 
that the production of visceral disease depends on two cireum- 
I stances — first, on the intensity of the congestion, and, secondly, on 
■ a frequent repetition of the attack where the symptoms are less 
j violent. In this country, the latter seems to be the principal cause. 

From these considerations, we come to the important law that, 
| after some time, we are not warranted in looking upon ague as a 



I 



422 STOKES'S THEORY AND PRACTICE. 



simple fever, but as a fever of a compound nature, involving affec- 
tions of many important viscera, to which we must attend carefully, 
if we seek to practise with safety and success. It is singular, that 
the majority of medical men appear to look upon the effects of 
an intermittent as being very circumscribed. You have all heard 
of enlargement of the spleen. Now, I have known some practi- 
tioners who appeared to think that this was the whole pathology of 
intermittent fever ; in fact, that there was a very close connection 
between enlargement of the spleen and ague. This, I need not 
tell you, is a very imperfect view of the question; the spleen 
suffers like other viscera, but there is no separate relation between 
its enlargement and the production of intermittent fever. The 
reason why attention has been chiefly directed to it is, because its 
lesions are generally more manifest than those of other viscera. It 
is composed of a loose, spongy, erectile tissue; it receives in its 
natural condition a great quantity of blood; it becomes rapidly and 
extensively enlarged during the cold fit; and hence it becomes a 
very prominent and remarkable sign of the disease. But I believe 
that in all cases where the spleen is found to be enlarged you will 
also be able to detect disease of the liver or lung. All the viscera 
are more or less liable to suffer under similar circumstances; there 
is, in a word, no single acute or chronic disease which may not be 
the result of intermittent fever. In this country, it generally gives 
rise to chronic disease ; in w r arm climates, acute visceral inflam- 
mation is more commonly the result. Here we arrive at another 
very important consideration, namely, that it may happen that the 
phenomena of an intermittent shall cease, and yet the chronic dis- 
ease produced by the violence or persistence of the original malady 
will continue. This is exceedingly common. We frequently meet 
with chronic disease of the heart, lungs, or brain, with dysentery, 
diarrhoea, peritonitis, affections of the kidney, and chronic inflam- 
mations of the liver and the spleen, brought on by intermittent 
fever, in this country. These Jocal affections are the result of 
violent congestion, and the continued irritation which accompanies 
the early paroxysms of the disease ; and though the symptoms of 
ague may subside, the morbid irritation, which has been set up in 
the constitution, may proceed to such an extent that death may be 
the result of a complication of visceral affections thus produced; 
and this I believe to be the history of many chronic cases of ague. 
Chronic affections of the lung, liver, brain, and digestive system, 
are, then, the chief things to be dreaded or guarded against in a 
case of intermittent fever; for after all that has been said about the 
enlargement of the spleen, it seems to me to be the least important 
of the visceral lesions which follow ague. It appears in almost 
every instance (at least as far as we can see of it in this country) to 
exercise but very little influence over the economy. In warm 
climates, indeed, it is sometimes so much enlarged as to produce 
serious inconvenience by its pressure and bulk. Thus, in South 
America, it has been observed, that in bad cases of ague the spleen 




INTERMITTENT FEVER. 



423 



I has become so enormously increased in size as to fill nearly the 
I whole abdominal cavity, producing great derangement of the diges- 
tive organs, and actually hernia. Dropsy, jaundice, chronic hepa- 
I titis, diarrhoea of an intractable character, various nervous affections 
j amentia, an atrophied state of the system, phthisis, hectic, typhus, 
I all these constitute part of the morbid affections which follow in 
I the train of ague as it appears in this country, and all will be found 
| connected with various chronic visceral lesions which have been 
j the immediate results of the original disease. 

When called to treat a case of ague which has been going on for 
| some time, you will generally meet with one of too things ; you 
may find that the viscera have, or that they have not, suffered 
| much from the effects of congestion. Now, when organic changes 
of viscera take place, we have the remarkable circumstance of their 
active tendency to keep up the original malady. Here you will 
frequently see practitioners prescribing bark, and if you watch its 
operation, you will sometimes find that it does more harm than 
good. But if, on the other hand, attention be directed to the local 
j lesion, neglecting the intermittent for some time, you will find that 
j the removal of the local disease brings back the intermittent, more 
or less, to its original state of simplicity, and renders it amenable 
to the specific. Observe the importance of this. The same rule 
I holds in intermittent as in continued fever ; you must practise 
| with an eye to the state of the viscera, and recollecting that the 
disease, which results from one as well as the other, may be, in its 
, turn, cause and effect. Here I shall take an opportunity of making 
a few observations with respect to a theory of intermittent fever 
which has been put forward by such high authority that we cannot 
pass it over. I allude to the theory of M. Broussais, in which he 
endeavours to show that intermittent and continued fevers are 
reducible to the same form, namely, an irritation of the digestive 
system. To this view T of the question a great many facts are 
opposed, all tending to prove that disease of the digestive system 
(which is so common in intermittent as well as continued fever) is 
to be looked upon more as an effect than as a cause. It is absurd 
j to say that intermittent fever is merely an intermittent gas-tro- 
enteritis, when dissection shows that we have not only disease of 
| the digestive tube, but also of the heart, lungs, and brain. The 
J fact of coexisting visceral inflammations was passed over by M» 
j Broussais, and certainly it must be acknowledged that this is a 
j very simple mode of getting rid of a strong objection. His doc- 
| trine was, that fevers, intermittent as well as continued, are only 
i examples of the effects of irritation of the digestive system, the con* 
! tinued fever being significant of severe and extensive disease, the 
I intermittent of an affection of a milder character. He also main* 
; tains that the rigors are produced by, and proportionate to, the 
; internal irritation. Nov/, admitting, for argument's sake, the two 
I first propositions, what do we find to be the fact 1 That in con- 
I tinued fever, where the irritation is greatest, the rigors are compa- 



! 



424 



STOKES'S THEORY AND PRACTICE. 



i 



ratively trifling, while in the intermittent, where the irritation is 
less violent in degree, the rigors are remarkably intense. Here we 
see intense rigors with slight disease, and trifling rigors with 
intense disease, two facts strongly militating against the proposition 
ofM. Broussais. 

Another argument may be urged against these doctrines : I allude 
to the effect of bark. This is a point which very much puzzled the 
physiological school, and they have accordingly exerted all their 
ingenuity to explain it away. At first, I believe, they were strongly 
inclined to deny altogether the specific powers of this remedy ; they 
were subsequently, however, compelled to subscribe to the fact of 
its efficacy, which was too notorious to be denied, and they had 
then to explain how bark could cure a gastro-enteritis. Hard as it 
was to explain how bark could be instrumental in removing gastro- 
intestinal inflammation, it was a matter of unavoidable necessity to 
attempt something like an explanation, in order to maintain the 
integrity of the physiological doctrine. They therefore set about 
the task, and endeavoured to show that bark cures the ague, or its 
cause, gastro-enteritis, by substituting one irritation for another. 
The whole gist of their arguments is founded on this point: — 
quinine, they say, is a stimulant ; ague is the irritation produced 
by gastro-enteritis. Now, it is a fact that stimulants will frequently 
remove existing irritations ; thus, we frequently observe, that blen- 
norrhagia, chronic ophthalmia, and diarrhoea, are cured by stimu- 
lants. This argument, however, is more specious than solid. 
There are certainly cases of irritations of mucous surfaces which 
may be removed by stimulants, but these are cases of chronic and 
not of acute disease. No one would dream of employing stimu- 
lants in a case of acute febrile diarrhoea, few would think of apply- 
ing irritants to an acutely inflamed and painful conjunctiva; it is 
only when the character of the inflammation alters, and the affec- 
tion acquires more or less chronicity, that these remedies prove at 
once serviceable and safe. Now this is not the case in ague. If it 
depends upon an acute gastro-enteritis, we are, according to this line 
of argument, to conclude, in the teeth of their other doctrines, that 
the best mode of curing an acute attack of gastro-enteritis is to stimu- 
late the inflamed mucous surface. Here, you see, we arrive at the 
argument ad absurdum. Another observation on this subject : — 
In a case of intermittent fever, supposing it to depend on gastro- 
intestinal irritation, it is a matter of indifference whether you give 
the bark during the paroxysms, or during.the intermissions. Now, 
it is a matter of experience, that bark will be far more effectual 
when given during the intervals of apyrexia. Again, if bark cured 
by producing a new irritation, we ought to see the symptoms of 
that irritation succeeding the administration of the remedy. 

Thus, whether we look to the symptoms, the appearances seen 
on dissection, or the results of treatment, and the efficacy of bark, 
we must conclude that the morbid state of the digestive system 
stands in the relation of effect, and not of cause. As far as we can 




INTERMITTENT FEVER. 



425 



judge of ague, it appears to be some profound alteration of innerva- 
tion, some affection of the whole system, the nature of which we 
cannot understand, but the effects of which we perceive in the 
various derangements of internal organs, by which it is attended. 
Intermittent fever is not intermittent gastro-enteritis, because dissec- 
tion reveals various other important lesions, and because it is cured 
by bark, which has nothing in it calculated to remove acute inflam- 
mation. We know that if a patient labouring under ague has acute 
inflammation of the stomach, bark, so far from curing, will do him 
a great deal of harm. Bark cannot cure by exciting irritation, 
because, if it did, it would increase the supposed gastro-enteritis, 
and w r e should have more violent symptoms during the intermissions, 
the time when it is always given, than during the paroxysms. 
Lastly, there is no analogy between the effect of stimulants on acute 
and chronic inflammations. What the modus operandi of bark is, 
we cannot explain. Many things, connected with the phenomena 
of life in health and disease, are, and probably will forever remain, 
concealed from human ken. We daily witness the effects of 
stimulants, but we cannot explain their mode of action. This, 
however, is no opprobrium to medicine. This is the right way of 
viewing the subject ; part of it is capable of admitting an explana- 
tion, the rest constitutes a portion of the inscrutable arcana of 
nature. It fortunately happens, however, that, for all practical 
purposes, the knowledge of these occult portions of medical science 
is as yet comparatively unimportant. 



LECTURE XXXVIII. 

Intermittent fever — Symptoms— Occasional irregularity of the paroxysms — Convulsive 
motions of the foetus in a pregnant woman during ague — Exciting causes of ague — 
Treatment — Complication with other diseases — Importance of careful investigation 
— Visceral lesion, how far contra-indicating the use of bark — Bark almost a specific 
in ague — Large doses of quinine in ague — Rapidity of its operations in some cases 
— Fowler's solution of arsenic — Prussian blue — Its advantages. 

Let us proceed with the subject of intermittent fever. I gave 
you, at our last meeting, an analysis of the phenomena which 
accompany the paroxysms of this disease, and endeavoured to 
show that intermittent fever was not reducible to any form of 
I fever symptomatic of local inflammation, but that it was, as far 
j as we could see, an original affection of the system, connected in 
! all probability with some profound lesion of innervation. I shall 
. now proceed to a brief review of some of the more prominent 
' symptoms. 

1 The first approach of a paroxysm of ague is, generally speaking, 
I pointed out by a degree of languor and debility more or less marked. 
| The patient, without any apparent cause, becomes weak and rest- 
j less, throws himself on a bed or couch, feels chilly, and has a 



426 STOKES'S THEORY AND PRACTICE. 



sensation as if a stream of cold water was running down his back ; 
his features are considerably shrunk, and his skin pale and corru- 
gated. In some cases the surface of the body is cold, and I believe 
in most cases the patient has a strong sensation of cold, even though 
the skin may continue warm during the rigor. By degrees the 
chilly sensation which is first felt along the back extends to all parts 
of the body ; the patient begins to shiver ; has horripilatio and chat- 
tering of teeth ; and as the symptoms increase, the rigors are so 
violent as to shake the bed on which he lies. The sensation of 
cold now becomes intense : he calls for warm drinks, and begs of 
his attendants to heap more bedclothes on him. He is anxious, 
restless, and uncomfortable, and if questioned answers briefly and 
with reluctance. His pulse is small, weak, and irregular; the 
action of the heart oppressed, and respiration more or less laboured. 
The general sensibility is impaired ; in some cases there is delirium, 
in others a state of stupor amounting to apoplexy. Headache is 
most commonly present, and there is often pain in the loins and 
sides. The situation of the patient is indeed truly pitiable ; he lies 
beneath a heap of bedclothes, with his teeth chattering, his whole 
frame agitated by the shiverings, an icy sensation running through 
his whole frame, and which neither warm drinks nor accumulated 
covering can relieve. Add to this the headache, the delirium, the 
stupor, the nausea, and diarrhoea, and you have the picture of suf- 
fering complete. This extraordinary condition may last for some 
time. It is generally terminated by a copious attack of bilious 
vomiting, when the rigors begin to decline, and are succeeded by 
alternate flushings of heat. The rigors now cease ; the flushings 
become more frequent and protracted; the patient begins to feel 
the return of heat; the skin becomes gradually hot, and this in- 
creases until the heat gets far above the natural standard, being in 
some cases as high as 110°. In a few cases, particularly in warm 
climates, the temperature during the hot fit has been known to 
exceed this. Accordingly, as vascularity returns to the surface, the 
features lose their contracted appearance and the skin its paleness ; 
the face becomes full and flushed, the limbs regain their ordinary 
dimensions, and the skin becomes smooth and almost tense. The 
nausea and vomiting abate, the patient is hot and thirsty, and has 
scanty high-coloured urine. The pains in the loins and back still 
continue, the headache is generally increased in intensity, and the 
tendency to delirium greater. The pulse is strong, quick, and 
bounding, and all the symptoms of high inflammatory fever are pre- 
sent. After some time, a tingling sensation is felt all over the body, 
accompanied by a degree of moisture, which soon increases to a 
copious and universal perspiration. With this all the unpleasant 
symptoms subside; the patient seems to luxuriate in his relief; 
thirst, headache, fever, vanish altogether ; he declares that he is 
quite well, gets up, and continues in the enjoyment of apparent good 
health until the next attack. 

The length of time which the whole paroxysm may last will 



INTERMITTENT FEVER. 



427 



vary from one to twenty-four hours. I have seen the three stages 
pass through their course and subside in the space of an hour; on 
the other hand, I have known them last for a day — this, however, 
is very rare, 

I told you in my last lecture, that in this country we seldom 
observe those violent symptoms which characterize the agues of 
j warm climates. In the bad cases of those countries a train of 
symptoms occur marked by extraordinary intensity ; the patient 
! has violent convulsions and tonic spasms, a wild staring eye, high 
delirium, excessive vomiting and purging, terrific rigors during 
j the cold fit, and when the hot stage comes on, he frequently has 
fits resembling epilepsy or apoplexy, and inflammation of the brain, 
i or lungs, or digestive system. Sometimes two or all the great 
splanchnic cavities are simultaneously affected. 

It is generally believed, that in the different types of intermittent 
fever the paroxysms come on at particular periods : — thus we hear 
of the paroxysm of quotidian occurring in the morning, of tertian 
at midday, and of quartan in the afternoon. In Dr. Good's Study 
of Medicine, a work remarkable for its learning, you will find all 
these circumstances detailed with an elaborate minuteness, and you 
will see that the author has considered them of importance suffi- 
cient to make a generic difference between the various forms of 
i intermittent. Many of his observations, however, on this subject, 
j betray a want of accurate observation. The truth is, that in'every 
form of intermittent we may have the access of fever at any hour 
in the day. In the Meath Hospital we have found that the rule 
before laid down does not hold good ; for we observed that the 
paroxysms of both quotidian and tertian occurred at all hours of 
the day and night. Andral, in his Clinique Medicale, gives twenty- 
five cases of ague, of which eleven that were cases of quotidian 
came on between four and eleven in the afternoon. Out of seven 
cases of quartan, one came on in the morning, the rest in the after- 
noon. These facts show that the rule is by no means so general as 
has been imagined, and that it is not of sufficient importance to 
ground upon it any generic difference. There are also many 
varieties in the complications of intermittent described besides 
those which are witnessed in this country, but these I am inclined 
to think as being of very little value, for as yet we have no thera- 
peutic indication founded on the divisions of intermittent fevers 
quoad their type. However, as some of you may be hereafter 
I placed in such circumstances as to to find this species of knowledge a 
matter of importance, I shall make a few observations on the point. 

During an epidemic of intermittent fever, you will meet with 
some cases in which there will be an extraordinary regularity in 
' the access, duration, and intermission of the paroxysms, while in 
i other cases you will find them irregular as to the time of invasion, 
i the phenomena of the different stages, and the period of subsidence, 
j as well as the interval of apyrexia. This is what is called irregu- 
j lar ague, and seems to be the same as that which Frank has 

i - 



i 

! 



428 



STOKES'S THEORY AND PRACTICE. 



described under the title of febres intermittentes larvatce. These 
are cases in which, to use an expression common in this country, 
the ague has gone astray. In some instances we meet with a very 
peculiar type of intermittent, the double quotidian, or that form in 
which we have two attacks in the course of a day similar in their 
phenomena and character. This is a very rare form of the disease ; 
I have never observed it but on one occasion in the Meath Hospital. 
There is also another kind which has been called double tertian. 
In this variety, you have a paroxysm every day, but the coinci- 
dence between the nature of the paroxysms and the period of inva- 
sion is to be observed only every second day, just as if there were 
two tertians, each attacking on alternate 4 a ys. You have a pa- 
roxysm every day, one to-day at twelve o'clock, which is of a mild 
character, another to-morrow at the same hour which will be 
severe ; on the third day the paroxysm of the same character as on 
the first, and in this way you have, as it were, two fevers having 
their access on alternate days. There are some other varieties of 
intermittent fever, but they are so exceedingly 7 rare that I will not 
take up your time in describing them. 

The duration of an intermittent fever is subject to considerable 
variety, but, in general, they are tedious if not interfered with, and 
apt to assume a more or less obstinate character. Agues which 
occur in spring and summer subside much sooner, c ceteris paribus, 
than those which occur in autumn. Of all forms of the disease, 
quartan appears to be the most obstinate ; there are many cases of 
it on record which have lasted for years, indeed, it seems to be well 
established, that it may continue for a great length of time. In 
one very remarkable case it lasted for forty 7 years, and during that 
time the patient had his paroxysms every third day. Schenck 
gives the details of a case in which the patient had quartan from 
his birth, where, in fact, the disease seemed to be congenital. There 
is another remarkable one bearing on the same point. A female, 
labouring under an attack of tertian ague during her pregnancy, 
observed that on the alternate days, when she was well, the 
foetus appeared to be affected in a very singular manner. Violent 
convulsive motions of a certain character occurred at fixed periods, 
lasted for a certain length of time, and then regularly subsided. It 
would appear, that in this instance the foetus was afflicted with the 
same disease as the mother, nor is there anything improbable in 
the supposition. We have well established cases of the existence 
of ague from birth, and there is no reason why the nervous system 
of a child should not be modified in this way, as well as that of the 
mother. We know, too, that the foetus in utero is liable to many 
diseases, even of a chronic character, and it has been proved that 
they may have chronic inflammation of the mucous membrane of 
the digestive tube, abscess, tubercles, small-pox, and many other 
affecions. 

I shall say but little with respect to the exciting causes of ague. 
A common opinion, and one which is taken up by too many medi- 



INTERMITTENT FEVER. 



429 



cal men, is, that ague is generally produced by unwholesome ema- 
nations from marshes, or what has been termed malaria, or marsh 
; miasma. It cannot be denied, that in many cases we observe a 
I coincidence between the existence of marsh miasmata and endemic 
ague ; but it is to be investigated how far we are to believe in the 
existence of any separate and distinct miasm. There are numerous 
facts to show that other causes, the nature of which is much 
| more easily understood, are capable of producing all the varieties 
of intermittent fever. Cold and moisture are fully capable of pro- 
ducing ague, independently of any miasm whatever. In Sir G. 
j Baker's and Sir Gilbert Blane's writings you will see that in several 
instances no ague was found to exist in the marshy districts, while 
| in hot and dry situations it was endemic. My friend Dr. Dundas, 
who resided for some time at Bahia, mentioned to me some very 
| remarkable facts connected with this circumstance. The town of 
| Bahia is built in a low marshy valley, which is separated from the 
sea-shore by a range of high hills. The streets are narrow and 
filthy, and, being exposed to the direct influence of a burning sun, 
j it has everything in it calculated to produce unhealthy emanations. 
Yet it is a curious fact, that in the town ague is almost unknown, 
while, on the neighbouring highlands which separate the valley 
from the Atlantic, and where the soil is dry, and the air pure, it is 
endemic. When Dr. Dundas went to reside there, these hills were 
pointed out to him by the natives, and he was told that there was 
the ague country. This appeared so strange to him, that he did 
, not believe it until some time afterwards, when he had an oppor- 
tunity of correcting his error. A merchant who lived in the town 
with his family, all in good health, was attracted by the beauty of 
the hills, and wished to purchase a country-house which had every 
advantage of situation to recommend it. Before he removed his 
family thither, however, he was anxious to have Dr. Dundas' opi- 
nion as to the salubrity of the place. On arriving there Dr. Dundas 
found it in everything calculated apparently to promote health, a 
fine, dry, luxuriant soil, a situation commanding a range of beauti- 
ful scenery, an airy house, and a plentiful supply of excellent water. 
Under these circumstances, he thought he might safely recommend 
the place, and the gentleman removed thither accordingly. In the 
course of ten days the following occurrences took place. The mas- 
ter and one of the servants were attacked with violent intermittent 
( fever ; and an old female, of a low weakly habit, got symptoms of 
typhus ; two other servants were attacked with dysentery, and an 
j European gentleman who had joined the family a few days after 
j their arrival got intense pneumonia. In fact, almost every indivi- 
| dual of the party was laid up with some disease or other. Of this 
I variety of disease, occurring in cases where the exposure has been 
I the same, we have many analogous examples. You will find in the 
j writings of Dr. James Johnson, how an apparently similar case will 
I produce different diseases in different individuals. It may be ob- 
| served, however, that although these diseases differ in their seat, 

37* 



i 



430 



STOKES'S THEORY AND PRACTICE. 



they do not differ in their nature, being all referable to the same 
pathological condition, namely — irritation of organs. 

I shall now proceed to consider the treatment of intermittent 
fever. Suppose you are called to treat a case of ague, and have 
ascertained its history, type, and period of access, &c, what are 
you to do 1 Here, gentlemen, let me entreat of you to lay this down 
for yourselves as a rule never to be departed from, that before you 
prescribe the slightest medicine you first make an accurate and 
perfect survey of the state of the viscera. I do not mean to say 
that you may not be able in a great many cases to arrive at a 
proper and successful mode of treatment without taking this trouble; 
but, if you succeed in many, you will be certainly disappointed in 
some, if you neglect the state of the viscera ; whereas, by adopting 
this rule you will always be on the safe side. Depend upon it, that 
if medical men were to do this more generally than they do at 
present^ it would render their practice more certain, and tend to 
raise the character of medicine. The great error of medical prac- 
tice is the absurd habit of prescribing for names and not diseases. 

Well, then, the first thing you do is to ascertain precisely the 
nature of the disease, and see whether it be an original and essential 
intermittent, or one of a secondary nature and depending upon 
local lesion. You are aware that we have many cases of continued 
fever, which are the results of local lesion, and we may in like 
manner have the symptomatic in intermittent as well as in con- 
tinued fever. Now the whole nicety of treatment turns on this. 
If the case be one of the essential kind we know the remedy which 
will answer, if not in all, at least in the majority of cases. If it be 
symptomatic, your treatment must be directed to the removal of the 
local lesions. It would be wrong to begin the treatment of a case 
of urinary intermittent by giving bark ; it would be equally absurd 
to pursue the same course in any other intermittent depending on 
local irritation. It would be only exasperating the disease, at the 
same time that its cause is allowed to continue. If the patient has. 
come from a situation where ague frequently prevails, there is a 
chance that it is a case of essential, and not of symptomatic, disease. 
If ague be raging as an epidemic at the time, it is very probable 
that any one particular case is of the same description. But you 
are not for these reasons to conclude that it is a case of essential 
intermittent ; if you did so, without investigating its precise nature, 
your practice would be empirical, and probably unsuccessful. I 
recollect on one occasion, after the subsidence of an epidemic fever, 
we had a vast number of cases of ague in this city. Previously to 
this period the few cases we had were generally imported, the 
patients being in almost every instance poor Irish labourers, who 
had been engaged during the autumnal season in agricultural labour 
through the fenny districts of England. These poor fellows fre- 
quently exhibited symptoms of ague on their arrival in Dublin, and 
of such the majority of our patients consisted ; but, after the epi- 
demic of 1826, we had a vast number of cases in and about Dublin. 



INTERMITTENT FEVER. 



431 



At this time we frequently had from a dozen to twenty ague patients 
in the Meath Hospital together. 

During the early part of this period, a patient came in with all 
I the symptoms of well-marked tertian. He had a regular cold, hot, 
and sweating stage about noon on every second day, and a distinct 
interval of apyrexia. In this case I made no examination, but, 
| taking it as one of a simple essential character, I put the patient at 
once on the use of quinine. On the day of the next access, I was 
! surprised to find that the paroxysm was much more severe than 
! the one which preceded it. On the next day I observed that the 
I type had changed, and that it was now a double tertian. This led 
! me to suspect that something was going wrong. On turning down 
I the bedclothes to make an examination, I was struck with the enor- 
mous size of one of his legs, and found that he was labouring under 
; phlebitis, with oedema. I immediately ordered his bark to be dis- 
continued, applied leeches along the limb, and had him put on- a 
strict antiphlogistic treatment. In the course of a few days the 
swelling of the limb was removed, and the intermittent disappeared. 
I mention this case to put you on your guard. In entering on the 
treatment of a case of intermittent, you must investigate several 
circumstances ; first, the character of the paroxysms, and whether 
they are of a mild or severe description, and how long they last; 
I next, the duration of the whole disease ; thirdly, and this is a point 
| of importance, whether the intermissions be complete or not; and, 
lastly, the nature and extent of the complications. By a careful 
investigation of these circumstances, you will be able to arrive*at 
the precise character of the disease, and can judge of the probability 
of the existence or non-existence of internal lesion. In my lecture 
of Saturday, you will recollect I stated that the liability to internal 
disease was in proportion to the duration of the ague, and the vio- 
lence of its paroxysms. If the disease be recent, and the paroxysms 
not violent, there is nothing, perhaps, to contra-indicate the use of 
bark. By carefully examining the intermissions, you will arrive at 
some very important conclusions. You will find them either perfect 
or imperfect. Now, if they are imperfect, if there is not a state of 
complete apyrexia between the paroxysms, it points out one of two 
things, either that the disease was from its commencement more of 
a remittent than of an intermittent character, and, consequently less 
under the influence of bark, or that the febrile condition is kept up 
by some local internal disease. If you find on examination that in 
the early period there was complete apyrexia, but that this is no 
longer the case at the time you see the patient, the great probability 
is, that it is some organic visceral affection which keeps up the 
fever during the intermissions. You now proceed to examine the 
I state of the viscera, and first the nervous system. Observe whether 
; there is any headache, lesion of intellect, or stupor; whether there 
j is any affection of the muscular system, any derangement of sensi- 
bility, any throbbing of the vessels of the head and neck, or any 
| signs of inflammation of the brain. Go then to the chest, and 



432 STOKES'S THEORY AND PRACTICE. 



carefully investigate its actual condition. Here you will derive 
great advantages from the use of the stethoscope and percussion. 
In all cases of any considerable duration, never omit making this 
examination, for in ague, as in continued fever, viscera] affections 
are remarkable for their latency. A patient may have the lung in 
a very dangerous state, and yet during the periods of apyrexia will 
not present any remarkable symptom. I have seen cases w T here 
the lung w 7 as actually solidified from repeated congestion, and yet 
the cough was but trifling, and the distress of breathing slight 
during the intermissions; but when you applied the stethoscope to 
the posterior and lateral portions of one or both sides of the chest, 
they were found to be completely impervious. You then proceed 
to examine the belly. See whether it is flat, or prominent and 
swelled ; whether it is tender on pressure, and where the tender- 
ness is greatest ; inspect your patient's tongue, and ask him has he 
thirst, nausea, or diarrhoea ; observe whether the solid viscera of the 
abdomen are enlarged or not, and carefully note the condition of 
the liver and spleen. It is necessary to make this examination in 
every suspicious case, and you can do it easily and rapidly. In the 
majority of cases which have lasted for any considerable time, you 
will hardly fail to detect some internal lesion. 

Here we arrive at a very important question. Does the existence 
of any amount of visceral lesion necessarily contra-indicate the use 
of bark 1 The answer to this question is — the mere existence of 
visceral lesion does not contra-indicate the use of bark, if the lesion 
be slight and recent, and does not keep up febrile irritation after 
the cessation of the paroxysms. If the lesion has not arrived at 
that state in which it becomes reciprocally cause and effect, it does 
not present any obstacle to the employment of bark. A slight 
degree of bronchitis may be present, but you should not on that 
account suspend the use of the specific ; trifling enlargement of 
the spleen may exist, but this should not alter your practice. In 
these cases the lesions are trifling, and do not react on the system, 
and in all such cases bark may be given with a reasonable prospect 
of success. 

I shall commence the treatment of ague by at once recommending 
to you its great specific. If there is anything in medicine which 
deserves the name of a specific, it is bark in ague. I do not mean 
to say that this is to be received in the full sense of the term, for 
there is no such thing as a complete specific. There are many 
cases of symptomatic ague made worse by bark, and the same thing 
is to be said of cases of essential ague, where the local lesions stand 
in the light of cause and effect. The more the case is free from 
visceral disease, the more simple and essential in its character it is, 
the more certain will be the action of quinine. Many persons com- 
mence the treatment of a case of ague by unloading the bowels. 
To this practice there is no objection, and it has many advantages. 
It is not however absolutely necessary, and may sometimes be 
dispensed with ; but if you do it gently, avoiding strong irritating 



INTERMITTENT FEVER. 433 

i 

I purgatives, it is an excellent mode of preliminary treatment. You 
may give the bark in large doses at considerable intervals, or you 
J may give it in small and frequently repeated doses. There is some 
difference of opinion as to the comparative value of these two 
modes. Our experience with respect to this point is, that you will 
cure an intermittent more certainly, easily, and with less loss of 
quinine, by giving it in large doses at considerable intervals. Thus, 
if you treat a case by giving ten grains of sulphate of quinine in a 
single dose once a day, you will cure your patient sooner than if 
you gave the same quantity in a day in divided doses. 

You will find it stated in books, that the interval between the 
! paroxysms is the best time for giving bark. Of this there can be no 
[ doubt ; not because the powers of bark are greater at one time than 
another, or that they are impaired during the paroxysms, but it is 
difficult to give a patient in that state any kind of medicine, for the 
stomach is generally irritable, and will not bear it. But it is a fact 
that you can give it at any period, and it is remarkable how rapidly 
its febrifuge properties will sometimes act. There is no doubt that 
| its effect may be, to a certain extent, produced in the course of an 
hour. I have seen cases w T ith bad paroxysms to-day, and on the 
next day have observed that a dose of quinine, given during the 
paroxysm, has produced a sensible effect. 

It is a matter of little consequence what way the quinine may be 
administered. You may give it in pills, in solution, or in the form 
of enema. The latter seems to be the most convenient mode of 
giving it to children who will not swallow the pills or the solution. 
I If you take four ounces of water, four grains of sulphate of quinine, 
a few drops of dilute sulphuric acid, and a few drops of laudanum 
or liquor muriatis morphias, you have an excellent febrifuge injec- 
tion, and you can vary the proportions of quinine and opium 
according to the age and condition of the patient. In employing 
this injection, you should recollect that it is given to be retained ; 
the bulk should therefore be small, and it should be of a medium 
temperature, neither hot nor cold. If you find on the following 
day that the paroxysm, instead of coming on at twelve, is delayed 
until two o'clock, it is a sign that the bark is acting favourably ; if, 
on the next accession, the paroxysm is still further protracted, you 
may be sure the patient will soon get well. In some cases the 
disease has been cut short by giving a single large dose ; but as far 
as I can judge, it appears to me that the best way is to remove it 
gradually. It is a curious fact, that when the ague has been 
arrested at once, new local diseases have supervened. In all cases, 
therefore, where the symptoms have rapidly and suddenly disap- 
j peared, you should be on the look-out for new symptoms. 

Of all remedies for ague, quinine appears to be the best. I have 
I made a number of comparative trials of sulphate of quinine, Fow- 
| ler's solution, and the per-ferro-cyanuret of iron. All these remedies 
I were found to have a good effect ; among them, however, quinine 
| holds the first rank, next in value is Fowler's solution, and then 



! 



434 



STOKES'S THEORY AND PRACTICE. 



Prussian blue. I may remark here, that the introduction of Prus- 
sian blue is a great improvement in medicine. It may be given 
with safety, it is a remedy of no ordinary power, and from its 
cheapness is particularly adapted for dispensaries and institutions 
where the funds are limited. We have given it in doses of from a 
scruple to half a dram three times a day, and though it is inferior 
to bark, still it is a remedy from which much advantage is derived. 

At our next meeting I shall speak of the endermic mode of using 
quinine, and lay before you some curious researches on this subject 
made in France; and these, with a few additional observations, 
will conclude the treatment of intermittent fever. 



LECTURE XXXIX. 

Use of quinine—Disease not a simple increase or decrease of vitality — Barks a specific 
in ague — To be given in the period of apyrexia — Large doses at considerable inter- 
vals — Arsenic followed by dyspepsia — Mercury, its effects in ague — Treatment dur- 
ing the paroxysms — Dover's powder, heat, laudanum, carbonate of ammonia — 
Pressure on large arteries to arrest the cold stage — Used in a case of hydrophobia with 
temporary relief— Gastric-intermittent — Endermic mode of using quinine — Bleeding 
in the cold stage — Generally with safety and advantage — Supervention of other dis- 
eases — [Miasm not a cause of intermittent fever — Visceral obstruction and inflam- 
mation relieved by venesection in the hot stage and in the interval — Cold bathing — 
Mercury — Modifying influence of climate — Effects of arsenic — Case of malignant in- 
termittent — Little variety of tonics necessary for the cure of intermittents.] 

At our last meeting I spoke of the use of quinine in intermittent 
fever. With respect to its modus operandi I may observe, that 
we know as little of it as we do of that of other remedial agents. 
The truth is, that this part of medical knowledge is still involved 
in great obscurity, and that we know almost nothing of the mode 
of action of various medicines. But that different remedies have 
different actions, and that there are such things as specifics, seems 
to be established, and this fact of the existence of remedies, which 
may be termed specific, is a strong argument against the formula 
which has been proposed for all diseases by the school of Broussais, 
viz., that they are reducible to a plus or minus degree of local 
vitality. If this were the case, the peculiar applicability of the 
properties of bark and mercury,' for the cure of certain affections, 
could not exist. The fact of particular remedies possessing a power- 
ful influence over certain diseases shows, that there is something 
in those diseases more than a mere increase or decrease of vitality, i 
and that in such instances there is some modification in the pheno- 
mena of vitality, which only admits of being modified, or removed, 
by the action of certain remedies. One of the most remarkable 
instances of the adaptation of peculiar remedies to peculiar diseases, 
is the use of bark in pure ague, and I believe I may safely say, that, 
in pure simple intermittent, bark may be justly called a specific. 

In speaking of the use of bark in intermittents, I showed that it 
might be given either during the paroxysms or the intermissions, 
but that it was much better to give it during the period of apyrexia, 
on account of the greater facility of exhibition, and because there 



INTERMITTENT FEVER. 435 

j was less chance of its being rejected by the stomach. Having 
j alluded before to the different modes of using bark, I shall not take 
, up your time with this part of the subject. Happily for medicine, 
j quinine has completely superseded the use of bark ; but where you 
! cannot get quinine, you may employ the bark itself, either in the 
I form of powder, electuary, decoction, or tincture, 
j With respect to the question whether it is better to prescribe 
1 large doses of quinine at considerable intervals, or to give it in small 
! and repeated doses, I have stated, that as far as our experience in 
1 the Meath Hospital went, it was decidedly in favour of the practice 
| of giving a large quantity at once. The best way appears to be 
' to order the patient to take ten grains of quinine at a single dose, 
j about two or three hours before the paroxysm comes on. In Italy, 
! where ague of a severe character is frequently met with, the quan- 
i tity given at a time is much larger, fifteen and twenty grains being 
i often taken at a single dose by an adult. In some cases as much 
' as one hundred and eight grains have been taken before a cure has 
been accomplished. You can easily understand why such large 
I quantities are prescribed, when you recollect that in Italy and other 
' warm countries, w 7 here pernicious ague prevails, it is of the utmost 
I importance to introduce the remedy as soon as possible into the 
system, for if you are not able to cut short the disease soon after 
the first or second paroxysm, the patient may fall a victim to its 
violence. Professor Speranza, in his excellent medical reports, 
defends this practice, and observes, that it is absurd to maintain 
that the doses of medicines should be the same in all countries ^ 
! and when we consider the different intensities of particular diseases 
; in different countries, we must allow that there should be some 
variation in the dose. 

I spoke of arsenic as one of those remedies which exert a consi- 
derable influence over intermittent fever. This medicine, which 
was imported from the East, was first strongly recommended to 
the profession by Dr. Fowler, who has given a formula for employ- 
ing it, and there is no doubt that it possesses febrifuge properties. 
It is stated, that, in consequence of the establishment of a smelting 
house for copper, in a particular district of Cornwall, ague, which 
frequently appeared in that situation, has entirely ceased. You can 
understand this by recollecting, that in the smelting of copper ore, 
arsenic fumes are often copiously extricated. 

Sir Gilbert Blane states, that in the ague which prevailed among 
our troops at Walcheren arsenic was used with good effects in cases 
where bark would not be borne. In these cases it was generally 
prescribed in combination with opium and aromatics. Under cer- 
tain circumstances, also, it may be employed with greater advan- 
I tage than bark ; but as a remedy it is decidedly inferior to bark, 
and there is one objection which applies to it, but not to bark, 
namely, that in several cases where arsenic had been employed in 
| the cure of this and other diseases, the patients, after their recovery, 
| fell into a state of bad health, became weak, emaciated, and pre- 



436 



STOKES'S THEORY AND PRACTICE. 



sented remarkable derangement of the digestive organs. Some of 
these persons sunk in the course of a few years, others continued 
to drag on a miserable existence. In several instances, where 
large quantities of arsenic had been taken for the cure of skin dis- 
eases, I have observed that the patients never recovered from its 
effects, and there can be no doubt that it is a substance highly 
inimical to the system, and that its long continued use is productive 
of mischievous results. We should, therefore, decline its employ- 
ment whenever we can dispense with it, and though we may not 
be able to procure Peruvian bark, or sulphate of quinine, we should 
recollect that there are many other astringent barks possessed of 
febrifuge properties, and which may be employed with safety and 
advantage. 

It has been proposed to cure intermittent fever with mercury, and 
this requires a few observations. In cases where mercury has been 
used instead of bark, it has been observed that the disease has been 
checked for some time, but that as soon as salivation disappeared 
the disease returned. It produces a suspension of the paroxysm, 
but does not eradicate the complaint. It is related, that in two 
ships-of-war, whose stock of bark happened to be exhausted at a 
time when ague prevailed extensively among the crews, the medi- 
cal officers had recourse to mercury, and it was found that as soon 
as salivation was established, the paroxysms of ague disappeared. 
But three-fourths of the patients thus treated relapsed when the 
salivation disappeared, and this happened even in cases where 
mercury had been used three or four times for the same affection. 
Mercury is certainly of great utility in removing some of the 
diseases consequent on intermittent, but it does not appear to pos- 
sess any specific power over the disease. The fact of the subsi- 
dence of the paroxysms of an ague on the establishment of mercurial 
action has many analogies, for we all know that there is a vast 
number of diseases which will subside as soon as the mercurial 
action is set up in the system. 

I shall now draw your attention to some other circumstances 
connected with the treatment of intermittent fever, and first with 
respect to the management of the paroxysms. In the cold stage, 
there is scarcely anything necessary but to keep the patient well 
covered, and give him mild warm drinks. In very bad cases, the 
use of the warm foot-bath, the application of warm bricks, or stupes, 
to the feet, and small quantities of warm wine, or carbonate of 
ammonia, will be required ; but I would advise you to be sparing 
in the use of internal stimulants, unless the cold fits are extremely 
severe. We may venture to say (and this applies to cholera as well 
as to the cold stage of ague) that the extent and danger of reaction 
and its accompanying diseases in the hot stage is often proportioned 
to the quantity of stimulants used during the cold stage. There is 
one remedy, however, to which this remark does not apply, namely, 
opium — this may be given with advantage at the commencement 
of the paroxysm. A dose of laudanum will diminish the duration 



INTERMITTENT FEVER. 



437 



and violence of the cold fit, without increasing the hot, and if com- 
bined with some preparation of ipecacuanha, its effects will be still 
better. What we generally give in the Meath Hospital is, from ten 
grains to a scruple of Dover's power. Dr. Fordyce mentions a 
case of quartan ague which was cured in a few days, after having 
resisted the use of bark for two years. Two hours before the 
paroxysm came on, he gave the patient a full opiate draught com- 
bined with a small quantity of carbonate of ammonia. The effect 
of this was to increase the quantity of perspiration during the 
sweating stage, and produce a change in the character of the 
paroxysms. The disease then came under the influence of bark, 
and the patient was rapidly and permanently cured. This case is 
of great importance, as it shows that in some instances where the 
disease resists the use of bark, it may be rendered amenable to it 
by first making an impression on the system with opium, and then 
trying the specific. 

A curious circumstance in the treatment of the cold stage of 
ague is the effect of pressure on the extremities. If you apply 
strong pressure to the extremities, particularly in the vicinity of 
their nerves> it is a fact that the rigors, even though they may be 
remarkably violent, will often cease. This I have seen very often. 
I remember when J was a pupil at the old Meath Hospital, a little 
boy who was labouring under intermittent, used to send for me as 
soon as the rigors came on, and beg of me to " hold him," as he 
said, while the shivering lasted. My practice in this case was to 
| compress the anterior and internal parts of the thigh and opposite 
arm with all my force, and I have observed that in almost every 
case where pressure was employed, the hot fit came on much 
earlier than usual. The same thing was observed by Dr. Kelly in 
1794. He advises the use of the tourniquet for this purpose, and 
states that, in some cases, the hot fit came on in three minutes after 
its application. It is difficult to explain how the tourniquet acts in 
arresting the cold fit ; at present, I believe, we must confess our 
ignorance as to its mode of operation. It, however, goes to prove 
that ague is a nervous disease, for if it were an intermittent gastro- 
enteritis, as the physiological school teach, how could it be possible 
to remove it by pressure on the extremities ? Besides, we have 
analogous instances of the same effects being produced by pressure 
in other diseases of the nervous kind. We have them, for example, 
in hysteria and epilepsy. In a very remarkable case of hydro- 
phobia, which was, some years since, under the care of my father, 
pressure on the extremities was attended with very singular results, 
i The patient, a female child, w,as brought into the Meath Hospital, 
j with symptoms of well-marked hydrophobia, which had come on 
j some time after she had been bitten in the foot by a rabid dog. 
| The tourniquet was, by my father's direction, applied over the 
middle of the thigh of the bitten extremity, and he found that as 
soon as it was sufficiently tightened, the spasms ceased, and the 
hydrophobic symptoms disappeared, for the patient could drink 



438 



STOKES'S THEORY AND PRACTICE. 



freely, and without inconvenience. During the course of the night 
the paroxysms came on again ; on making an examination, it was 
found that the tourniquet had become loosened, and had slipped 
downwards ; on being again tightened the paroxysms ceased. 
After thirty-six hours the tourniquet was removed, and the parox- 
ysms again returned with all their original violence. During the 
course of a clinical visit, the patient was asked if she had taken 
any drink ; she replied she had not, and dared not make the attempt 
unless the tourniquet was applied. This was immediately done, and 
she drank freely. In this case my father proposed amputation, but 
nothing was don% and the little patient died, with all the terrific 
symptoms of the disease. It is a curious fact, however, that, in 
this case, the paroxysms were arrested, and the progress of the 
disease clearly suspended, by the use of the tourniquet. 

There is a form of intermittent, common in warm climates, and 
not unfrequent in this country, to which the name of gastric-inter- 
mittent has been applied by Frank, and which is generally met 
with in the autumnal season. This disease is known by the pre- 
sence of symptoms of gastro-enteric irritation combined with the 
phenomena of ague. The symptoms of gastro-enteric disease may 
be recognised, not only during the paroxysms, but also during the 
intermissions. The patient complains of thirst, nausea, and loss of 
appetite ; there is a desire for cold drinks, the tongue is loaded, and 
the epigastrium tender on pressure. The skin is slightly yellow, 
the eyes have a semi-jaundiced appearance, and the urine is turbid 
and high coloured. In the treatment of this affection, Frank re- 
commends us to commence with an emetic. I cannot speak from 
experience of the utility of this practice ; he, however, recommends 
it very strongly. The plan which I would advise you to pursue is 
the following : you must here hold in view, that there is a combi- 
nation of intermittent fever with local disease of the gastrointes- 
tinal mucous surface, and that the latter demands your attention as 
much as the former. In some cases the gastric irritation is so con- 
siderable, that if you were to proceed at once to the use of bark, 
you w T ould in all probability do mischief. After having directed 
such measures as will abate the violence of the paroxysms, I gene- 
rally begin with the application of leeches to the belly, and the em- 
ployment of all the ordinary means to relieve gastro-intestinal irri- 
tation. By this mode of treatment, you will find that the gastric 
character of the disease will disappear in a great degree, and then 
you can have recourse to bark with safety. In a few cases I have 
observed, that even without the use of bark, all the symptoms of 
ague have been removed by treatment directed to the gastro-intes- 
tinal disease. If they do not, you can easily give quinine ; and 
where the irritation has been subdued, it will act both safely and 
expeditiously. Allow me to repeat the circumstances under which 
you recognise the necessity of leeching and other measures to re- 
move the affection of the digestive tube. These circumstances are 
drawn chiefly from the state of the patient during the intermissions, 
for in this kind of ague we seldom have complete apyrexia. Thirst, 



INTERMITTENT FEVER. 



439 



nausea, foul tongue, epigastric tenderness and fulness, a semi-jaun- 
diced state of the skin and eyes, and turbid high-coloured urine; 
these are the symptoms which mark the coexistence of gastric 
disease with ague ; and, under these circumstances, I would advise 
you never to omit leeching, the use of purgative injections, mild 
mucilaginous drinks, and every other means calculated to remove 
gastro-enteric irritation. When you have accomplished this, you 
may then employ quinine with safety. 

There is one point connected with the treatment of this form of 
intermittent which you should be acquainted with. It occasionally 
happens, that the symptoms of gastro-eiiteritis will disappear, but 
the tongue still continues foul. It is a common opinion in this 
country, that the tongue -is a correct index of the state of the 
bowels ; and the inference in such cases would be (according to 
this opinion) that in these circumstances it would be improper to 
prescribe bark. If nothing remains, however, but foulness of tongue, 
it should not prevent you from giving bark, for the state of the 
tongue here is connected with the morbid condition of the whole 
system, and not with disease of the digestive tube. 

I shall now proceed to make some observations on the endermic 
mode of using quinine. A number of curious and interesting re- 
searches have been made on this subject not long since in France, 
and it is necessary that you should be acquainted with them. In 
some cases bark or its preparations cannot be taken internally; the 
stomach will frequently reject the remedy ; and in cases of inflam- 
mation of the digestive tube its employment would be dangerous. 
It has been stated, however, by those who have used it in the 
endermic mode, that even in cases of ague complicated with gastro- 
enteritis, they have been able to accomplish a great deal of good, 
and that quinine may be always employed in this way with safety. 
The first author who wrote on this subject was M. Martin, who 
published a memoir on the endermic mode of using quinine, in the 
Archives Generates. In this memoir he states, that the application 
of quinine to a blistered surface, even where the quantity employed 
was very small, never fails in arresting the symptoms of ague. 
You are to observe, however, that quinine cannot be employed in 
this way in its simple state ; if this were done, it would excite a 
high degree of irritation, and the proper effect of the remedy would 
not be obtained. One of the most severe and troublesome forms of 
ulceration I have witnessed for a long time, occurred in a case 
where quinine in its simple state had been applied to a blistered 
surface. Over the whole extent of skin to which it had been ap- 
plied, numerous ulcerations took place, which resisted for the space 
of six weeks every attempt to heal them. But it is a singular fact, 
that when quinine, reduced to a fine powder, is incorporated with 
a certain quantity of cerate, no such effect is produced. The ad- 
vantages of this mode of using quinine are, first, that it can be 
safely employed in cases where its internal use is dangerous, as in 
the case of gastric intermittent ; secondly, it is stated that a smaller 
quantity will be required than if taken internally ; thirdly, that it 



440 



STOKES'S THEORY AND PRACTICE. 



will act more rapidly ; and lastly, that it can be employed with 
advantage in cases where the patients are averse to taking medi- 
cines internally. These are the grounds on which M. Martin 
claims a superiority for the endermic mode of using quinine. He 
further remarks, that it cannot be supposed to act as a counter-irri- 
tant when used in this manner, for any local irritation produced by 
it would exert an unfavourable influence over its effects, and render 
them less certain. All this may be easily understood by recollect- 
ing what the phenomena of absorption are, and how they are pro- 
moted or obstructed. Where the application of quinine has caused 
a considerable degree of irritation, a quantity of gelatinous fluid 
will always be thrown out, and this must obviously prevent the 
entrance of the remedy into the absorbent vessels. In proof of this 
M. Martin gives some cases. A robust man, aged thirty-five, had 
been labouring under an attack of quartan ague, for which he had 
taken bark internally four times shortly before he came to consult 
M. Martin. When seen during the hot fit of the next paroxysm, 
his skin was intensely hot; he had cough, mucous expectoration, 
and rapid laborious breathing ; considerable excitement of circula- 
tion, and a red dry tongue. Sixteen ounces of blood were taken 
from his arm on account of the pulmonary symptoms. In three 
days after, the paroxysm returned as usual, and on the next morn- 
ing a blister was applied, and the raw surface dressed with six 
grains of sulphate of quinine mixed with a quantity of cerate. 
From this period he had no return of the ague, and his general 
health improved. In this case no irritation attended the applica- 
tion of quinine. He gives another remarkable case. A woman, 
aged twenty-three, who had oppression of breathing, pain in the 
chest, and cough, was attacked with quartan ague in the month of 
September, but recovered under treatment. The ague again re- 
turned in the following December, accompanied by hard, quick 
pulse, difficulty of breathing, and cough. In this case also vene- 
section was performed. The patient had then four grains of qui- 
nine applied to a blistered surface, and the paroxysms never returned. 
The blistered surface in this instance was somewhat red, but the , 
irritation disappeared rapidly. In both these cases you will observe, 
that bleeding was performed before quinine was employed, and, so 
far as they go, they cannot be looked upon as unexceptionable 
examples of the cure of intermittent fever by the endermic mode, 
as from the researches of Dr. Mackintosh, we learn that many 
cases of the disease will recover after- bleeding in the cold stage 
alone. 

M. Lembert. another writer on the same subject, states, that in 
ten minutes after the application of quinine to a blistered surface 
on one of the extremities, a sensation of gentle warmth diffused 
itself along the limb towards the trunk, and so on over the whole 
body. The hot fit, says he, also comes on much sooner than usual, 
and the violence of the whole paroxysm is diminished. The sen- 
sation of warmth is coincident, according to his account, with a 
diminution of its symptoms and an increase of muscular power, 



I 



INTERMITTENT FEVER. 441 

| and he thinks that Jhe reduction of heat during the paroxysms is 
I a necessary consequence of this mode of using bark. There is 
another case given, which exemplifies some of his statements. A 
stout young man, who had got ague during the expedition to Spain, 
presented himself with the usual symptoms of the disease, accom- 
I panied by foul tongue and a semi-jaundiced colour of the skin. 
J For the space of ten days, he took from eight to ten grains of sul- 
1 phate of quinine daily, but without any improvement. The quinine 
j was then applied to a blistered surface. His paroxysm came on 
1 after the application about the usual time, but its duration was half 
j an hour shorter than before. The next attack was also shorter, 
j and the fifth was prevented altogether by applying ten grains of 
| quinine at once. He was then considered to be cured, but about 
j fifteen days afterwards, in consequence of an error in diet, he got 
j another attack. The endermic mode was again tried, but without 
| success ; the internal use of quinine was then resorted to, and was 
followed by a perfect cure. 

These facts do not show that the external mode of using quinine 
I has any great advantage over the internal. Where it would be 
| improper to prescribe it internally, it is certainly a valuable mode, 
but it remains to be proved whether employing it in this way be 
preferable to give it by the mouth or in the form of enema. 

I shall now make a few observations on the last subject connected 
with the treatment of intermittent fever, and this is the proposition 
of bleeding in the cold stage, put forward so ably by my distin- 
guished friend Dr. Mackintosh, of Edinburgh. In the writings of 
almost all the older authors it was laid down, as an undoubted fact, 
that the cold stage of ague was essentially a stage of debility ; they 
saw that the cold stage of intermittent fever was attended with con- 
siderable prostration of the powers of life ; they regarded it as one 
of pure debility, and they completely overlooked its effects on the 
viscera. From an accurate observation of the phenomena of the 
cold fit, from perceiving that the signs of a retreat of blood from 
the surface to internal parts were evident, from ascertaining by dis- 
section that the viscera were overloaded with blood, and from recol- 
lecting that in chronic cases of ague visceral disease was of constant 
occurrence and often the cause of death — 'from all these circum- 
stances, Dr. Mackintosh was led to conclude that the old idea 
| respecting the cold fit was a mistaken one, and that much good 
j might be done by bleeding in the cold stage, so as to relieve the 
| congestion of internal organs. This idea he entertained for some 
; time without venturing to put it in practice, so strong were the 
I existing prejudices against any kind of depletion in what was 
! looked upon as a distinct example of debility; he ultimately, how- 
! ever, determined to make trial of it, and, with the self-devotion 
! which characterizes true science, first put it in practice on himself. 
; On being attacked with intermittent fever, he boldly rejected the 
| venerated dogmas of the school, and had himself blooded in the 
I cold fit. The operation was performed ; and so far from any of the 

38* 



I 



442 



STOKES'S THEORY AND PRACTICE. 



dreaded results occurring, it was followed by great relief. Since 
that time the remedy has been extensively tried, and he has given 
an interesting and detailed account of it in his admirable work on 
the practice of physic. 

An incorrect view of Dr. Mackintosh's opinion on the treatment 
of intermittent fever has been taken by some persons. It has been 
said that he neglects and disregards bark, and that he considers 
bleeding in the cold stage as the only remedy required for the cure 
of ague. This is not true. All that he proposes to establish is, 
that there is congestion of the viscera during the cold stage, and 
that although the phenomena of debility are present, blood may be 
taken away safely and with the greatest possible relief in many 
instances. Of course all those persons who are attached to the 
practice of studying and prescribing for names rather than actual 
diseases are still opposed to Dr. Mackintosh's treatment, for nothing 
shocks them so much as that which has a tendency to overturn 
and expose their favourite dogmas. For this reason they looked 
upon the new opinions as heterodox, and the practice as a danger- 
ous innovation. Notwithstanding all this, no sensible practitioner 
can entertain a doubt that Dr. Mackintosh has conferred a most 
valuable boon on medicine, first by demonstrating the real nature 
of the cold stage of ague, and, in the next place, by showing that 
bleeding may be performed in it with safety and advantage. 

It is a question, however, which remains to be discussed, whe- 
ther we can have recourse with safety and success to this mode of 
practice as the ordinary treatment of intermittent in this country. 
My own impression is, that, in this country, the practice is unne- 
cessary in the great majority of cases, and that you can remove 
all the simple cases of ague with certainty and safety, by means of 
the specific alone. I told you in a former lecture, that I had endea- 
voured to render my experience on this subject as extensive as pos- 
sible, and that during the epidemic ague of 1827, I had made trial 
of Dr. Mackintosh's practice on not less than one hundred patients. 
Now the general conclusions which I was induced to draw from 
an accurate examination and comparison of these cases, were, that 
in the vast majority, bleeding in the cold stage of an intermittent 
may be performed with safety ; that there is very little or no danger 
of the patient dying of debility, as was formerly apprehended ; and 
that, in many cases, this treament was found to diminish the vio- 
lence and ameliorate the character of the paroxysms, and, in some, 
had the effect of completely arresting the disease. Dr. Mackin- 
tosh has witnessed several cases in which bleeding in the cold 
stage has cut short the disease at once, and of this I am fully- 
convinced, but I believe it to be a rare occurrence. I have cer- 
tainly seen it in a few cases. In one instance, where the ague had 
resisted the ordinary treatment for a considerable time, the 
patient was cured at once by bleeding freely in the cold fit. As 
far as my recollection goes, the number of cases in which this 
singularly favourable termination occurred, did not exceed three or 
four. 



INTERMITTENT FEVER. 



443 



But, you will ask me, did I observe any bad effects to result from 
this practice ? I have seen some cases in which the cold and others 
in which the hot fit were increased in violence after bleeding in 
the cold stage. I have seen several cases in which the paroxysms 
were brought more closely together, and the period of their occur- 
rence anticipated. Now this is a very unfavourable occurrence, 
for the nearer an intermittent approaches to remittent fever, the 
more unmanageable it is, and the less is it under the influence of 
bark. This observation has been further confirmed by my friend 
Mr. Gill, who went into the fenny parts of Lincolnshire, during the 
prevalence of an epidemic ague, to put the practice to the test. In 
a communication which he made to me on this subject, he states 
that he felt quite certain that he had it in his power to convert 
many cases of intermittent into continued fever by bleeding in the 
cold stage. 

We observed also in the Meath Hospital some other effects, 
which, however, do not particularly apply to bleeding in the cold 
stage, as they have been observed to follow the employment of other 
measures, — I allude to the supervention of new diseases. I have 
seen cases of intense pneumonia, of inflammation of the brain, and 
of gastritis, occurring immediately after the disease had been cut 
short by bleeding. This, however, is no argument against the 
practice of Dr. Mackintosh, for the same thing might happen 
where the paroxysms had. been arrested by bark. I have hazarded 
a conjecture in one of my clinical lectures, that if bleeding in the 
cold stage were useful, it would be chiefly in the intense agues of 
warm climates. Where life is threatened by the violence of the 
congestion, or by the excess of inflammatory action in warm coun- 
tries, in such circumstances I think bleeding may be looked upon 
as a valuable remedy in intermittent fever. Since that period, Dr. 
Mackintosh has received a number of communications from the 
East Indies, and from these it appears that the practice has been 
attended with great success. 

I may remark, in conclusion, that the foregoing observations 
apply to almost all the cases which came under our care in the 
Meath Hospital, for in almost every instance we were obliged to 
have recourse to bark after the use of the lancet, and we could not 
say that the patients required less quinine than those who had not 
been blooded. However, in all cases of intense congestion, but 
particularly in the pernicious ague of warm climates, I think this 
practice of great utility, and I am almost inclined to think that it 
may be employed with advantage in cases where bark, after a 
sufficient trial, does not exert any influence over the disease. 
Under all circumstances, the medical profession is deeply indebted 
to Dr. Mackintosh, for being the first to demonstrate the real 
nature of the cold stage of ague, and that the visceral congestion 
may be relieved by bleeding; and it is to be remarked that my 
chief trials of the treatment were made on the cases of an epidemic 
fever, a circumstance which of course diminishes the value of my 



444 



STOKES'S THEORY AND PRACTICE. 



results, as arguments against the treatment of sporadic or ordinary 
cases. 



[In imitation of the wise reserve displayed by Dr. Stokes, by his 
abstaining from merely historical and speculative disquisitions on in- 
termittent fever, I shall content myself with making a few statements, 
the result of long and large experience, on the treatment of this dis- 
ease. It gives me pleasure to find that the able lecturer's views 
accord with those which I have held for many years on the subject 
of miasm or malaria. Unexpectedly to myself, and whilst engaged 
in collecting and arranging all the facts and arguments in favour 
of the doctrine of miasm being the cause of both intermittent and remit- 
tent fevers, I was led to the conclusion that these diseases, whatever 
might be their real cause, did not depend on this, the generally re- 
ceived one. For the process of reasoning by which I reached this 
conclusion, I would refer the reader to a paper of mine on this sub- 
ject in the volume of Dr. Chapman's Medical and Physical Journal, 
for 1825. I showed on that occasion that periodical fevers are met 
with in mountainous districts, where the usually alleged sources of 
miasm are not found ; that these fevers have prevailed with violence 
in dry and sandy soils, and that they have been brought on by 
various crude ingesta, by cold, and by local irritation, without the 
persons thus suffering having been previously exposed to marsh 
effluvia. After an examination of the evidence in its favour, and 
of the influence of the known and appreciable states and changes 
of the atmosphere in the production of intermittent fevers, I used 
the following language, which now, after the lapse of years and 
farther study and observation, I still am disposed to repeat, as 
follows : 

" In conclusion, I think we are justifiable in the present stage of 
this inquiry, in denying the existence of any such separate, peculiar 
or specific morbid cause, as miasm or malaria. The attempts to 
explain its origin and production are so far entirely unsuccessful, 
and involve those who persevere in them in a tissue of contradic- 
tions, which would not be adduced or received by any known laws 
of evidence." 

Of the treatment of intermittent fever I have spoken in another 
publication {North American Medical and Surgical Journal, vol. 
viii. 1829). My practice as then laid down was in conformity with 
principles nearly analogous to those so instructively set forth by 
Dr. Stokes. The lecturer dwells chiefly on venesection in the cold 
stage. My own experience has led me to think highly of it in the 
hot stage, and also in the interval. But on this and other points of 
practice I shall content myself with reproducing, in the same words, 
the statements and opinions which I advanced in the paper already 
referred to, as follows : 

" The call for moderating excessive excitement is not less im- 
perative here than in other maladies, distinguished by similar symp- 
toms, however variously named. We are well aware of the general 



[ INTERMITTENT FEVER. ] 



445 



principle on these occasions, that the risk of subsequent languor and 
engorgement or even of disorganization of the organs and disturbance 
of function, is greater if the excitement be allowed to wear itself 
out by our abstaining from those means calculated to moderate it 

" In the case before us, we Irave, superadded to gastric irritation 
of the stomach, a morbidly exalted action of the other great viscera. 
Of course, in addition to the indications furnished by the former, we 
have those supplied by the latter, to direct us to the use of the lancet 
and the application of cold. In fact the treatment here is identical 
with that in every febrile paroxysm of any intensity, whether it be 
of regular or spurious and malignant intermittent, or remittent, yel- 
low, or bilious. It is true that a temporary crisis will generally 
I take place in regular intermittents without any interference on the 
| part of the physician ; but every paroxysm, especially if neglected 
i or mismanaged, predisposes the subject of it to complications and 
s aggravations, at each successive return ; and the stomach, liver and 
: head, from being periodically affected, are after a while permanent 
sufferers. 

! " Blood-letting in the hot stage of intermittent fever, thus pointed out 

j by inductive reasoning, has been proved by experience to be on 
many occasions decidedly beneficial. It is now many years since, 

| whilst yet a student in Virginia, it became my duty to see and oc- 
casionally prescribe for a young man of a thin spare habit of body, 
who had been much reduced by repeated attacks of intermittent 
fever. Bark and arsenic had been administered in vain. Jnflu- 

! enced by the recommendation of Senac, whose work on Intermit- 
ting and Remitting Fevers I had just perused, I opened a vein in the 
arm of my patient during the next hot fit, and took away a pint of 
blood. The relief was immediate ; the force of the paroxysm soon 
subsided ; the apyrexia was complete; and a few doses of bark were 
sufficient to prevent the next fit. He speedily recovered his health 
and strength, and remained clear of intermittent fever. From that 
time to the present I have not hesitated to use the lancet in every 
case of periodical fever, in which either the apyrexia was not so com- 
plete as to leave the patient entirely clear of all gastric and cerebral 
distress, or in which the paroxysms had been of frequent recurrence 
and untractable under the use of the bark. I have usually preferred, 
when the choice was in my power, bleeding during the hot stage 
to doing it in the apyrexia ; but the experience of every additional 
season convinces me that in this latter state also, the employment 
of the lancet will realize all our best hopes. 

" Cold Bathing. — Both as adjuvant to and substitute for the lancet 
in the hot stage, cold affusion or immersion is entitled to special 

j notice and favour. The tranquillizing and pleasurable effects of 
cold water to a patient in the burning heat of fever, must be actu- 

! ally experienced by an individual before he can properly appreciate 

| them. The chief obstacle to the use of this remedy, now that the 
prejudices of ignorance are in a great measure dissipated, consists 
in the want of suitable conveniences for bathing among the larger 



i 



446 



STOKES'S THEORY AND PRACTICE. 



portion of those who suffer from intermittent fever. Seldom, how- 
ever, shall we be unable to procure a large tub for the patient to 
stand or crouch in, and one or two buckets, the contents of which 
are to be poured on him. Sponging the surface of the body may be 
had recourse to for the purpose of allaying the morbid heat in the 
hot stage; but it is an indifferent substitute for immersion or affu- 
sion, unless in particular cases and circumstances of age, sex and 
states of mind of which we can readily conceive. 

" Coinciding with the effects of cold water, externally applied, 
will be those from its internal use. In lieu of water in its simple 
state, we may give it slightly acidulated with lemon juice, or cream 
of tartar ; or, if the stomach be much distressed, gum arabic will 
be a useful addition. 

" Having by these means brought our patient through the cold and 
hot stages, the sweating will seldom be excessive or enfeebling, and 
the succeeding period will more probably be, not in name, but in 
fact, that of apyrexia. Should it prove such, that is, should the 
tongue be moist and but little loaded, and the skin soft, we can then, 
with every prospect of entire success, give the bark or its salts 
in full doses at short intervals, until in the revolution of time the 
epoch arrives at which the next paroxysm would probably have 
come on. 

" It will be seen that I am not so exclusive as to recommend 
blood-letting and cold as remedies, which, if used during the hot 
stage, are of themselves capable of curing intermittent fever. But 
thus much I can aver, that the febrile exacerbation will be briefer 
in duration and diminished in violence, the succeeding interval freer 
from all unpleasant sensations, and the return of the paroxysm 
postponed, and when it does come, rendered less violent after the 
use of the lancet. 

"If the period following the paroxysm be not one of complete 
apyrexia, and there remains some heat and tenderness in the epi- 
gastric region, with a tongue furred, and red at the borders, we shall 
for the most part only increase the general discomfort of the patient 
by administering bark and other tonics, wine and rich food ; even 
though, by this treatment, we prevent the coming on of the next 
paroxysm. The case is to be treated in all points as we would 
treat gastric irritation under other circumstances, viz., by simple 
drinks, and very light bland nutriment and moderate exercise, with 
pediluvium or the warm bath. 

" I do not speak of the state of the pulse during the apyrexia, be- 
cause I consider the indications which it furnishes as very fallacious. 
It is most common to find it exhibiting under the finger a certain 
degree of activity, compounded of fulness with vibration, in the 
progress of intermittent fever : but this resistance furnishes hardly 
any reason for depletion, if the stomach be sound, tongue moist, and 
skin soft ; nor would its smallness and feebleness be an argument 
for prescribing the bark, or abstaining from general or local deple- 
tion, or both, if the stomach were much distressed, the head pained, 
the hypochondria tender and tumid. 



[ INTERMITTENT FEVER. ] 



447 



" I hold it as a fair inference from pathological phenomena, jus- 
tified by large experience, that, in this last mentioned condition of 
j things, blood-letting, in the interval of intermittent fever, is as safe 
I and efficacious as in any other form of disease whatever. It re- 
j moves phlogosis of the mucous membranes of the digestive and 
i pulmonary apparatus, so often combined in the subjects of intermit- 
j tent fever, at the beginning of winter and spring; as well as pre- 
vents engorgement of the liver and spleen, and aids in removing it 
if once formed. The prevention of the paroxysm becomes, after 
the use of the lancet, a most simple affair. Pounds of bark or 
| drachms of quinine have been given in vain to cure an intermittent 
fever, which has in a short time completely yielded to a few doses 
of these medicines when their administration was preceded by a 
| single bleeding. Of this fact, I have had numerous examples : and 
I so much were the patients themselves surprised at the prompt relief 
I afforded, that, overlooking the bleeding, they imagined the quinine 
pills which they had taken afterwards to be a new medicine, pos- 
! sessed of uncommon and peculiar powers. What is said of general 
I bleeding will apply in many cases to topical depletion, by means 
; of leeching or cupping. The predominance of gastric symptoms 
would point out the propriety of applying leeches over the epigas- 
trium ; the complication of pulmonary ones would indicate the use 
of cups to the chest. Whether blood-lettingfrom the arm shall precede 
these operations must depend on the intensity of the visceral dis- 
ease and the circumstances of the constitution, and general habit of 
I body of the patient. Venesection will of itself most generally meet 
our expectations, if a regulated and reduced diet be persevered in, 
so that the stomach, ceasing to be offended, may recover from its 
state of irritation. 

" By an adoption of this plan, if we do not entirely remove the 
periodical paroxysms, we at least reduce them to their simplest 
element, or that of nervous irritation. Nutrition even may now go 
on, and the individual's health not be materially deteriorated. But, 
as before remarked, we need not subject him to the experiment. 
Bark or some kindred tonic will now readily suffice to accomplish 
a perfect cure. Very different is the result, when, without regard 
to the capillary system and the membranes which it mainly com- 
poses, we are satisfied to destroy the periodicity, and nurse our- 
selves with the illusion that we have removed the disease, because 
1 we have suspended the return of pure nervous irritation. 

" Mercury. — Of other remedies during the interval of intermit- 
tent fever, I deem it needless to say much, because every year 
diminishes for me the number, by my discovering the greater success 
attending a few than many. Were I required to speak of any one 
medicine, laying claim to pharmaceutical activity, which I have 
! used with most advantage in a period often necessarily intervening 
between the use of the lancet and the employment of the salts of 
quinine or the bark, I should unhesitatingly instance the blue-pill, 
j Not unfrequently, when the disease prevailed so extensively in this 

! 




448 STOKES'S THEORY AND PRACTICE. 



city and its vicinity a few years ago, I gave a five*grain pill of the 
blue mass at night and the cinchonic preparations during the fol- 
lowing morning, with the effect of promptly arresting quotidian 
fevers, which had not yielded to the bark, alone. The practice is 
equally applicable to tertian fever. I must add, however, that when 
this course was followed, I had not recourse to the lancet with the 
same freedom as subsequently. Blood-letting simplifies the practice 
so much, that we are enabled in the majority of cases to dispense 
with any intermediate medication between it and the use of the 
bark. I have indeed prevented a return of the paroxysm by giving 
five-grain doses of the blue mass three times a day, after bleeding; 
but although this will in some instances be entirely successful, I am 
far from recommending it as a general rule of practice. 

"With still greater hesitation would I encourage a perseverance 
in the use of the mercury until salivation had been produced. I 
have seen the fits suspended by the mercurial disease, but I have 
never known a patient to escape from a speedy relapse if the cin- 
chonic preparations had been withheld. Twice in my own case, 
when suffering from the disease in China in the year 1818, I ar- 
rested the disease by slightly touching the gums, but a relapse soon 
followed on the very first exposure to the night air in one case, 
and to an easterly wind in the other. Removal to the sea-shore at 
Macao and a few doses of bark, restored me to comparative health, 
and allowed me at the proper season to discharge my duty as the 
medical attendant on the American shipping then lying (at Wham- 
poa) below Canton. 

" Modifying Influence of Climate.— In illustration of the modifying 
influence of climate on the progress of disease and the effect of re- 
medies, it is but right for me to state that during the months of 
September and October, when there were most sailors in that port, 
and when the intermittent fever was rife, I was not baffled in a 
single instance in my attempts to cure, by a very simple treatment, 
those subjected to this disease. Sometimes evacuations were pre^ 
mised ; at other times the ceremony was waived. The chief re- 
liance was on the bark in drachm doses, administered at intervals 
of every two hours ; beginning at the expiration of one paroxysm, 
and continuing the medicine until about an hour before the epoch 
at which the next would have come on, if no curative measures 
had been adopted. Rarely did a patient suffer from the third 
paroxysm of a quotidian, or the second of a tertian ; nor was he 
long in being restored to ship duty. 

" It is not easy for me to pronounce to what extent these men 
would have suffered from relapses had they, remained in Canton 
during the winter, or what was the state of their health in the fol- 
lowing spring at home ; but I have reason to believe that relapses 
with them were not unfrequent. Be this as it may, I have not found 
the above simple practice answer in our own country, in which, 
from the excesses and vicissitudes of climate, visceral inflammation 
and engorgement are so common : while the same relief is not af- 
forded as in tropical regions by copious cutaneous transpiration. 



[ INTERMITTENT FEVER. ] 



449 



" Occasionally we hear of practitioners relying exclusively on 
the use of the cold bath for the cure of intermittents. A knowledge 
of the directly sedative effects of cold, and an observation of its power 
of reducing febrile action to the normal healthy standard, as in the 
hot stage of intermittent fever, will make us slow to direct it during 
the interval, when there is often little or no superfluous excitement, 
and the predisposition to chill is manifestly great. It is hardly wise 
to imitate a paroxysm of fever by subjecting an individual, whose 
nervous system is rather enfeebled than excited, to a cold bath. He 
is necessarily chilled; has some rigors; and in the most favoura- 
ble state a subsequent glow and reaction. Nor does the disturbance 
end here ; pains in the limbs and head and languor are often com- 
plained of by those who use the cold bath, when the system is not. 
above the natural level of excitement. From these premises, not a 
little strengthened by experience, I should feel inclined to regard 
habitual cold bathing in the interval as a hazardous remedy, and 
rendered often mischievous by the prevalent errors regarding its 
modus operandi. Very different are its effects when used in the 
hot stage of intermittent, or in the more permanent capillary ex- 
citement of gastro-cerebral fever, usually denominated typhus. The 
morbid excitement of the sanguineo-nervous structures, entering 
into the composition of the membranes, and chiefly instrumental in 
the secretions, including that of caloric, is abated and often entirely 
removed ; the patient is rendered tranquil, and enjoys a pleasant 
slumber unbroken by the former irritations of heat and thirst. 
Just in proportion as the state of the patient during the interval ap- 
proaches to that exhibited in the hot stage will, cold bathing be 
useful, but not otherwise. Hence, if there be a steady dry heat of 
the skin, frequent pulse with thirst, and little or no appetite, we shall 
derive good effects from cold affusion in the period between the 
paroxysms. This remedy is not, therefore, as often taught, akin to 
bark ; the two stand opposed to each other in their effects, and 
their use is only properly called for under different and opposite 
circumstances : the one to allay morbid irritation and inflammation ; 
the other to excite and strengthen parts already feeble." 

In the opinions which follow on the administration of arsenic, I 
may be thought to be too exclusive. I reproduce them, however, 
without misgivings as to their salutary influence. 

" A review of the effects or arsenic in intermittent fever, that is on 
those labouring under the disease who have taken it, would, on calm 
and dispassionate reflection, induce us to wish that its use had never 
been proposed. The amount of mischief which it has produced 
must have been excessively great, and exceeding the good that it 
has been alleged to do, in the same proportion in which cases where 
it has been given in ignorance of its operation and the state of the 
system have exceeded those where it was administered with all the 
reservations and restrictions that could be suggested by cautious 
observation. We are told that it has cured when the bark has 
failed : but I think it has been sufficiently shown that if the bark fails 

39 



450 



STOKES'S THEORY AND PRACTICE. 



we have other duties to perform towards our patient than hunting 
out fresh tonics. When thus unsuccessful, we shall find the stomach 
irritated and perhaps inclined to phlogosis, or there is a chronic he- 
patitis and a tendency to dropsical effusions. Now, most assuredly, 
arsenic, even if it arrest the chill, is not the appropriate remedy in 
these circumstances. If we persist in giving it we do so at the peril 
of our patients, to whom we stand fearfully responsible for the chro- 
nic gastritis thus entailed on them. Three of the most obstinate 
cases of disease which were presented to my notice during last 
year, were of persons who had used Fowler's solution for the cure 
of intermittent fever. One was a young man from the country, who 
had been cured of the chills by this medicine, but who suffered 
greatly when I saw him from pain and heat of the stomach, which 
had supervened since he began using the solution. Two bleedings 
and reduced diet made him more comfortable ; but I was not per- 
mitted to see him entirely recovered in consequence of his return to 
the country. The second was of a young female, who when I saw 
her was greatly distressed by irritability of the stomach, with fixed 
pain and frequent vomiting; her pulse was hard and active; the 
appearance of the complexion and other symptoms induced a belief 
that she laboured also under hepatic disease. Upwards of two 
months elapsed before her digestive powers could allow of her using 
any food at all stimulating. During that period she was frequently 
bled from the arm and leeched over the epigastrium. The blue pill 
was administered, and after a while the sulphate of quinine ; but both 
these were soon omitted, as I found the state of her stomach aggra- 
vated by their use, and I was content, at last, to rely on depletion, 
general and local, as above, and occasionally a mild laxative and 
diluents. Under this treatment she so far recovered as to justify 
the use once more of the quinine ; by which, finally, the disease 
lost its periodical character and strength and health followed. The 
third case, also of a female, was characterized by nearly the same 
symptoms, but they were of less duration, and were finally removed 
by several bleedings, and by the use of the quinine. 

" It would be well for us to bear in mind that there are two modes 
of poisoning. The one sudden and acute, resorted to in moments 
of temporary insanity or impious despair, for the purposes of speedy 
self destruction, or with malice prepense to take away the life of a 
neighbour ; the other is a slower process, practised by empirics, 
when they pursuade the ignorant and credulous to swallow their 
nostrums, and, shall we add, by regular physicians when they direct, 
without due deliberation, their patients to use arsenic, corrosive 
sublimate, and some other half-dozen of heroical medicines. " 

My experience of blood-letting in the cold stage of fever is recorded 
in the following terms : — 

" In two cases in which I adopted this practice, the result was 
not of such a favourable nature. One was evidently benefited ; but 
neither in this nor the other was I dispensed from the necessity of 
subsequent bleeding before the disease was arrested. 



[ INTERMITTENT FEVER. ] 451 

" To these I ought to add a third, which, from its rare occurrence 
and the formidable nature of the symptoms, merits a more particu- 
lar notice. It was of a young mulatto man, who had been confined 
to his bed for three weeks by gastric remittent fever. The parox- 
! ysms came on at irregular intervals, and were always marked by a 
frequent and rather full pulse, acrid heat of the skin, especially 
j over the abdomen, and a burning thirst. Frequent bleedings from 
] the arm and cupping over the abdomen had been practised ; purga- 
| tives of a saline and mercurial character were occasionally admin- 
j istered, which gave some relief at the moment, but always left the 
j stomach and abdomen more tender to pressure, and the skin hotter 
to the touch. During nearly the whole time the tongue was loaded 
in the middle with a whitish-yellow coat, while its borders and tip 
were red and shining. After the expiration of the above time con- 
valescence seemed about to be established ; the pulse was nearer a 
natural standard, thirst Jess urgent, and temperature of the skin, 
except over the epigastrium, of an ordinary nature. Pressure on 
the abdomen rendered the pulsations of the aorta very perceptible. 
The patient gained very little strength, although he was allowed 
! light animal broth and farinaceous food. Visited in the afternoon 
of September 17th of last year, (1828,) I found him in a state of 
great apathy, with an inclination to dose. The pulse was not 
materially altered, nor was there any other new symptom. A 
blister was directed to the back of the neck, and a laxative of rhu- 
I barb and magnesia at bedtime. At 11 o'clock p.m. I was sent for 
! in great haste, and on my arrival found the patient in a state of com- 
plete coma, utterly insensible to all objects of sight, sound, and 
touch ; his limbs at first extended, remained in whatever position 
they were placed; the pulse was barely perceptible, and the breath- 
ing very slow. It was impossible to make him swallow anything, 
or to elicit from him the slightest evidence of consciousness. On 
applying my hand to the epigastrium, I could feel the abdominal 
aorta beat with considerable force ; so also did the carotids. The 
contractions of the heart were frequent and laborious. The blister 
had been put on, but no medicine taken. Sixty leeches were now 
applied over the epigastrium, and sinapisms to the extremities. 
After the leeches had begun to fill, the pulse lost somewhat of its 
extreme tenuity, and by the time they were detached, it had re- 
gained its natural volume, was soft and easily compressible. The 
patient at this time began to move his eyes and the muscles of his 
mouth and face; he turned a little towards one side, yawned and 
stretched himself. The extremities were still cold and unaffected 
1 by the sinapisms. Before all the leeches were removed, the skin 
I became moist in places ; and finally a sweat covered the face, trunk, 
I and limbs, with the exception of the hands and feet. Enemata of 
; tepid water were administered at different times through the night, 
j In the morning, though languid, he was partially sitting up in bed, 
| by leaning on his elbow, helping himself to some light nutriment. 

In the afternoon of this day he experienced some rigors, which 
' disappeared in the evening in moisture on the skin. 



452 



STOKES'S THEORY AND PRACTICE. 



" On the evening of the following day, 19th, by eight o'clock, he 
was in nearly the same state as on the 17th, being completely co- 
matose. Cups in large numbers were now applied to the temples, 
and over the abdomen, so as to detract about ten ounces of blood. 
The effect was most salutary, and the recovery even more prompt 
than from the first attack. Enemata of cold water were given on 
the present occasion. 

"An examination of the symptoms of the case on the morning of 
the 20th, as presented by the pulse and skin, seemed to justify the 
use of the quinine, from which the furred and chapped tongue on the 
preceding days had deterred me. A minute inspection of this organ 
now showed me that under this dry and cracked coat it was pale, 
and rather thicker than natural. This appearance was readily re- 
cognizable by looking at the tip and sides of the tongue. A solution 
of the sulphate of quinine in water, ten grains to the ounce of fluid, 
was directed. Of this a tea-spoonful was taken every hour until 
the afternoon. There was then a very slight exacerbation. The 
medicine was resumed on the following day, and continued for 
several days. The patient was thenceforward clear of paroxysmal 
attacks, and gradually and regularly regained his strength and 
health. 

(i Here was an extreme case, in which the coma, evidently a sub- 
stitute for the cold stage of intermittent fever, was relieved on both 
occasions by a free abstraction of blood. The subsequent reaction 
and distress were very inconsiderable, and did not on either occa- 
sion prevent the patient from sleeping quietly during the remainder 
of the night." 

Were I to meet with a similar case of congestive or malignant 
intermittent, I should give five grains of the sulphate of quinine at 
once, and repeat the dose in two hours. Quite recently in another 
disease, epilepsy, from a misunderstanding of my directions, twenty 
grains of this salt of quinine were given in the early part of a day, 
without any perceptible increase of excitement, heat, thirst, or 
accelerated pulse. 

At first in Virginia, then in Canton (China), and subsequently 
during a term of twelve years as one of the physicians to the 
Philadelphia Dispensary, during part of which time the cases of 
intermittent fever were very numerous, I have had charge alto- 
gether of fully three hundred patients with this disease. I state 
this fact for the purpose of mentioning another, and of leaving the 
reader to draw from it the practical inference which it is my 
design to inculcate respecting the little necessity for hunting after 
new tonic or new combinations of tonics, if we place the stomach and 
viscera generally in a state fit to receive the quinine. Of these three 
hundred cases I do not think that I have used either vegetable 
bitters and astringents or arsenic in place of bark or quinine in ten 
cases ; and I do not remember to have experienced any great dif- 
ficulty in curing my patients in every instance except two. I do 



I 



[ INTERMITTENT FEVER. ] 



453 



not say that there was not relapses after they passed out of my 
hands : but of this I had no knowledge.* 

There is a remark made in the third paragraph of the pre- 
ceding lecture by Dr. Stokes, which should have a peculiar 
value in the minds of the American practitioner resident in our 
southern and western country. It is, respecting the largeness of 
the doses of quinine for the cure of intermittent fever in Italy. 
Similar toleration of the system to other remedies, such as tartar 
emetic, has been frequently recorded in the medical annals of that 
country. Now, an observation of the diseases of Italy and of those 
of the southern parts of the United States, will soon show no little 
resemblance between the two, and lead to the inference that, if we 
are to acknowledge European guides for the treatment of the 
latter, we shall find them more readily in Italy than in France and 
Germany, or in Great Britain. That I early formed this opinion 
will be manifest from the following, which is the closing, paragraph 
of a communication of mine to Dr. Chapman on the new Italian 
Doctrine of Counter- stimulus, published in the Third Volume of his 
Journal. 

" We shall conclude by expressing our ardent hopes, that the mind of the 
American practitioner may be more pointedly directed to the subject of Italian 
medicine. The great similarity of climate between the southern and middle 
sections of our country and Italy, the regular habits of close observation which 
mark her medical writers, and the liberal patronage extended to her schools are 
all so many forcible appeals to our attention. It is not detracting from the fame 
of the Scotch universities to assert, from firm conviction, grounded on ample 
opportunities of comparison, that the American student will obtain more useful 
and practical knowledge of the histories and treatment of diseases in the Medical 
Schools of Bologna and Pisa, than in those of Edinburgh and Glasgow. The 
teachers in the latter institutions may and do display learning and research: 
but those of the former, with no inferior acquisitions, will conduct us into the hos- 
pital, or direct our attention to the country around, and point out the great ma- 
jority of diseases, similar in nature and progress to those we meet with at home ; — 
from the yellow fever at Leghorn, to the intermittent and bilious remittent of the 
Campagna di Roma. Nor will they win our regard more by the solidity of their 
views than by the engaging affability of their manners, whereby they rouse us to 
exertion in soothing our self-love, and rendering us enamoured with our pur- 
suits." — R] 



* As the success of the treatment of intermittent fevers and the lives, it may be, 
of our patients depend so much on the purity of the quinine, it is desirable that 
we should be able at once to detect the adulterated article, which, to the disgrace 
of the parties concerned, enters too much into commerce. The substances 
employed with this view are, chiefly, mannite and gypsum. It is very easy for 
the druggistor physician to detect this adulteration by means of pure alcohol, which 
dissolves the sulphate of quinine, but leaves untouched either the mannite or the 
gypsum. In some packages in France sold as the genuine unadulterated medi- 
cine, there was not more than a sixth of its weight of sulphate of quinine. 



39* 



454 



STOKES'S THEORY AND PRACTICE. 



LECTURE XL. 

Continued fever — Varieties of fever infinite — Typhous fever— Symptoms of typhus — 
Petechiae, sign of typhoid character — State of the tongue various — Progress of the 
disease — Typhus produced by injection of putrid substances into the veins — Hemor- 
rhage from the intestines, &c. — Opinions on fever — Prognosis — Phenomena arising 
from each system — Jaundice an unfavourable sign. 

Before I enter on the consideration of exanthematous diseases, 
it will be necessary to examine the subject of ordinary continued 
fever. My reason for this is, that the phenomena of continued fever 
bear a closer relation to those of intermittent than they do to those 
of the exanthematous ; and as I have introduced the subject of fever 
by lectures which apply more obviously to the pathology of con- 
tinued than to that of exanthematous fevers, I think it better to con- 
clude this part before we proceed to the rest. 

I do not know of any subject so difficult to lecture on as fever. 
It is, in the first place, next to impossible to give any description of 
it which will apply to all, or even to the majority of cases. The 
varieties of fever are infinite. It varies according to situation and 
climate, to the peculiar character of the epidemic, the constitution 
and habits of the individual, and the numberless complications of 
local disease. One of the best modes of examining fever is to take 
a brief but general sketch of the usual symptoms of what is called 
typhus, and, proceeding thence analytically, to review fevers of a 
nervous type, or those in which the symptoms are chiefly referable 
to disease of the brain and spinal cord, together with their respective 
nervous connections ; next, to examine those fevers in which there 
is a predominance of diseased action in the respiratory system ; 
and, lastly, to ascertain the character of those in which the digestive 
tube seems to be principally engaged. , • 

You will recollect a principle which I have more than once im- 
pressed upon your attention, that we are to look on these fevers as 
general affections of the system, complicated, in the vast majority 
of instances, with local disease ; and that I stated that there was 
the greatest possible variety in the number, seat, and extent of these 
local affections. In some cases, they make their appearance almost 
at the commencement of the fever; in others, they supervene at a 
more advanced period. In some instances, they are confined to a 
single system, or even a single organ ; in others, the morbid action 
extends to all the splanchnic cavities. 

The symptoms of typhus may be divided into two classes — the 
precursory or latent, and the actual or manifest. The precursory 
are, more or less prostration of strength, a feeling of malaise without 
decided illness, an unusual paleness, a sensation of coldness and 
perhaps some shivering, a sense of weight about the head, indiffer- 
ence to objects of business or pleasure, troubled sleep and frightful 
dreams, some nausea, foulness of tongue, and loss of appetite. 
These symptoms may continue from a few hours to three or 
four days. In other cases, you will see the phenomena of typhus 



TYPHOUS FEVER. 



455 



setting in at once, and with an awful rapidity. This occurs 
chiefly in cases where a severe epidemic is prevalent, or where 
the miasm of fever exerts its influence over bodies of men, 
closely cooped up together, as we see exemplified in camp and 
jail fever. 

Typhous fever frequently sets in with a state of the system closely 
resembling inflammation. The skin is hot and dry, the pulse full 
and bounding; and this often leads the practitioner to think that 
he has to deal with ordinary inflammatory fever, and he bleeds 
with the expectation of cutting it short ; but it too commonly hap- 
pens that we are very seldom indeed able to effect this desirable 
purpose by blood-letting. You may succeed in modifying the symp- 
toms, but you cannot arrest the disease. It is, in fact, a question, 
how far general bleeding is admissible in the great proportion of 
cases of typhus. I shall examine this point more particularly when 
we come to the treatment of fever. If you take - blood from the 
system generally in this apparently inflammatory condition, you 
may find, in some instances, that the clot will be of a red colour, 
and crusted at top with a slight coat of buff; in other cases, you 
will perceive that the quantity of serum is trifling, the clot of a dark 
red colour, easily broken up, and without any buff. 

Whether bleeding has been performed or not, the pulse begins to 
alter about the third or fourth day, and this simulated appearance 
of inflammation goes away ; then comes a train of nervous symp- 
toms—anxiety, restlessness, delirium, tinnitus aurium, with an 
augmentation of the febrile symptoms towards evening. In the 
morning the patient feels better ; and this is almost always the case, 
for we seldom meet with a case of typhus without morning remis- 
sions. In some cases the symptoms are aggravated on alternate 
days, so as to bear some resemblance to double tertian. Sometimes 
the exhalant vessels of the skin are in a state of great activity, and 
the patients sweat profusely almost from the commencement of the 
disease. These cases we have found in the Meath Hospital to be 
extremely tedious. In the greater number of cases the skin remains 
dry, and this often continues through the whole disease up to its 
termination. With respect to the appearance of petechias, they 
may occur at an early period, or not until towards the close of the 
fever. The appearance of petechias has one particular value, as 
being a symptom most commonly connected with fevers of an essen- 
tial type, and rarely with those of a simple inflammatory character, 
or where the fever is symptomatic of local disease. Thus, we very 
seldom meet with petechias in the fevers which accompany cere- 
britis, or pneumonia, or gastro-enteritis. On the other hand, where 
the inflammation of these organs is secondary, and supervening on 
typhus, petechias are exceedingly common. 

As the disease advances, we observe other symptoms. The 
patient has more or less stupor, sighs frequently, answers briefly 
and impatiently when questioned; his eyes are red, glazed, and 
filled with the lachrymal secretion : his nostrils obstructed with 



456 



STOKES'S THEORY AND PRACTICE. 



adhesive mucus, which he repeatedly attempts to remove ; he is 
sometimes quite deaf, without any apparent affection of the ear ; 
his lips are dry and , chapped, and his teeth and gums crusted with 
a dark sordes. If you ask him to put out his tongue, he moves it 
slightly forwards, being unable to thrust it out fully, from its dry 
state and the injury of its muscular functions. Its upper surface 
is generally of a dark brown colour, or even black ; its mucous 
covering chapped and inclined to bleed, and feeling quite dry and 
relaxed ; but there is an infinite variety in the state of the tongue 
in typhous fever. Not unfrequently it is moist ; and I have seen 
cases in which it was nearly natural throughout the whole course 
of the disease. In many cases it is red, dry, tremulous, and pointed ; 
and in such cases we have generally observed symptoms of gastro- 
intestinal irritation. But it is a well-established fact, that we may 
have fever with gastro-intestinal disease, and yet without any cha- 
racteristic appearance of the tongue. In typhus, the tongue is not 
a correct index of the state of the intestinal canal ; and if you were 
to take it as the grounds of your diagnosis, you would often fall 
into error. You should, therefore, as I have before taught you, 
study the appearance of the tongue in fever more as indicative of 
the general condition of the patient than of the state of the gastro- 
intestinal membrane. You may have extensive disease with a 
natural tongue, and you may have a morbid state of the tongue 
without any appreciable intestinal lesion. You will often see in 
the advanced stage of fever a red, dry, and chapped tongue become 
pale, moist, and smooth, under the use of wine, carbonate of ammo- 
nia, and other stimulants; and yet, in such cases, if you were to 
judge by the tongue alone, you would say that there was inflamma- 
tion of the intestines, and that the employment of stimulants was 
dangerous; and, indeed, if it was ordinary inflammation, we know 
that it would be exacerbated by stimulants. 

In some cases of typhus there is thirst, and a desire sometimes 
for hot, sometimes for cold, drinks; in other instances, the patient 
drinks very little, and never complains of thirst. At one time wine 
is relished, at another time it is not. The skin varies as to its con- 
dition, being sometimes bedewed with profuse clammy perspirations 
of a well-known odour ; but in the greater number of cases it is 
dry and harsh. Sometimes there is diarrhoea, tympanitis, and ten- 
derness of the belly; occasionally it is soft and flaccid, and pres- 
sure is borne without inconvenience. The state of the urine, which 
engrossed so much attention in former times, cannot be looked upon 
as a diagnostic in typhus. In bad cases, it is, as well as the stools, 
passed involuntarily. This at first occurs during the patient's 
sleep, but as the disease advances it is passed unconsciously. It 
is not uncommon on the other hand, to meet with retention of urine. 

As the symptoms advance, the patient lies entirely on his back, 
quite indifferent to everything, with his lower extremities sepa- 
rated, and the trunk constantly sliding down in the bed from 
debility. The eye is dull, without meaning, and of an ecchymosed 



TYPHOUS FEVER. 



457 



appearance. During his brief and unrefreshing slumbers, the eye- 
lids are only half closed, and the eyeball is turned upwards. The 
delirium, feebleness of pulse, and prostration of strength, increase. 
A quantity of liquid faeces is discharged involuntarily, the belly is 
tympanitic, and hiccup comes on, which generally proves a very 
distressing symptom. At this period, also, we frequently have 
hemorrhagic discharges from various parts of the body — the nose, 
j stomach, bowels, and urinary organs. If the patient holds out for 
| any considerable length of time, bed-sores begin to form on the 
I back and loins, which are frequently surrounded by an erysipe- 
j latous border, and have a great tendency to run into mortification. 
The patient gradually gets weaker, his extremities become cold, 
his pulse thready, irregular, and indistinct ; the hiccup increases, 
and there is sometimes regurgitation. He now begins to sink 
rapidly, his eye is glazed, his jaw fixed, his face Hippocratic, his 
stupor increases, and he dies with tracheal rattle. 

The foregoing is a tolerably correct account of the symptoms of 
ordinary typhus, but of course it cannot be looked upon as com- 
| plete, for the symptoms of this disease are remarkable for their 
i great variety. With respect to the prognosis, it is also found to 
vary. Some patients will have almost all the symptoms above- 
mentioned, and yet may recover; but, generally speaking, the 
prognosis under such circumstances is unfavourable. The worst 
symptoms are those which point out lesions of the nervous system, 
and a morbid condition of the fluids. All the phenomena of nerv- 
| ous derangement, delirium, coma, subsultus tendinum, and spasms, 
are to be looked upon as unfavourable ; and. the same may be said 
of bad petechias, hemorrhages from the intestines and urinary 
organs. In cases presenting these symptoms, the prognosis is 
always of the worst kind. The most malignant form of typhus 
is that which arises among bodies of men closely crowded together 
— as we see in the camp, jail and hospital fevers. Here the disease 
appears to be the result of an excessive and highly-concentrated 
dose of the poison of typhus.* Where a number of persons are 
confined together in close apartments, you can easily conceive that 
the poison of the disease will act with tenfold severity, and it is in 
such cases that we often observe the phenomena of local inflamma- 
tion to be most extensive and violent. I have before alluded to the 
experiments of MM. Gaspar and Magendie, and mentioned the fact 
of fever, of a distinctly typhoid character, being produced by the 
injection of putrid substances into the veins of animals. Now, in 
those cases, it was observed that the greater and the more concen- 

I * [We may doubt the accuracy of this explanation. Whence can originate 
I " the poison of typhus" under the circumstances supposed ] The individuals thus 
! congregated were originally healthy. No one can be said to have primarily origi- 
nated the poison, nor to have transmitted it to, or inoculated his companion with 
it. The real poison, here, is in the carbonated blood, the retained excretions, 
and the associated and consequent disorder and deterioration of the nervous sys- 
tem. — B.] 



458 



STOKES'S THEORY AND PRACTICE. 



trated was the dose of putrid poison, the more closely did the conse- 
quent fever resemble bad typhus, and the more violent and extensive 
were the local inflammations. Now, if these local inflammations 
are in proportion to the quantity and concentration of the dose of 
poison, you can easily conceive why local disease should assume 
such threatening appearances in the jail and camp fevers. This 
excess in quantity and concentration in the virulence of the typhous 
poison, I look upon as the true cause of the malignant nature of 
these fevers. And if we take the reverse of these cases — if we look 
to the remarkable effects w T hich result from separating the sick 
from those who are in health — we have an additional light thrown 
on this subject. In cases of camp fever, it has been repeatedly 
observed, that, when the camp was broken up, and the sick sepa- 
rated into different parties, the fever totally disappeared, although 
the patients happened to be exposed to bad weather and the jolting 
of carriages. 

Before we proceed to analyse the symptoms of typhus as they 
appear in the nervous, vascular, respiratory, and digestive systems, 
it will be necessary to make a few T observations on petechia?. On 
this subject there are two opinions : one is, that they are analogous 
to the exanthematous eruptions, and, as it were, an attempt of 
nature to relieve the internal disease by external revulsion. An- 
other opinion is, that they proceed from a weakened state of the 
cutaneous capillaries, accompanied by a dissolved condition of the 
blood, and that they are in fact a kind of passive ecchymosis. I 
am inclined to think that we may adopt both opinions. There can 
be no doubt that petechia? are sometimes of an exanthematous cha- 
racter. We see them at an early period of the disease, when there 
is but little debility, and where there are no other signs of a morbid 
condition of the fluids ; and we know, too, that they are sometimes 
productive of relief, and that they form elevations, and desquamate 
like the exanthematous eruptions during the progress of the disease. 
All this proves that petechia? are sometimes to be looked upon as 
bearing a close analogy to the exanthemata ; on the other hand, 
we may find them without any of these characters, and presenting 
a livid or black colour. Quarin divides such into three classes — 
the red, the livid, and the black. The black are of the worst cha- 
racter, the livid are less dangerous, and the red are the most favour- 
able, though he does not say that they are entirely devoid of danger. 
It is the red petechia?, however, that are to be considered as having 
a resemblance to exanthematous eruptions. It sometimes happens 
that they are of very considerable size, simulating the appearance 
of purpura hemorrhagica. In the advanced stage of fever, large 
petechia? of a livid or black colour are dangerous, and point out a 
morbid alteration in the fluids. On the other hand, the earlier they 
appear, and the redder and smaller they are, the better, but when 
they occur at an advanced period of the disease, are of a dark 
colour, and accompanied by hemorrhages from the bowels or uri- 
nary organs, they may be looked on as indicating an unfavourable 



TYPHOUS FEVER. 



459 



I prognosis. Huxham looks upon them as sometimes critical ; I sup- 
j| pose he alludes to the first or exanthematous description. Pringle 

is of a different opinion. Our experience in the Meath Hospital 
J does not enable us to make any other remark on this subject, than 
j that we have seen them followed by some relief, but no exact or 

distinct crisis. The worst form in which they can appear is that 
I of vibices, or large dark spots like purpura hemorrhagica ; and in 
| this form, as Huxham observes, they afford grounds for making a 
! most unfavourable prognosis. 

It is hardly necessary for me to state that persons differ exceed- 
| ingly in their power of bearing up against an attack of fever. It 

is a fact, almost universally known, that one man may be favour- 
j ably circumstanced for resisting the disease, while another may be 

a bad and unfavourable subject. Anything that has a tendency to 
I weaken and depress — as excessive apprehension, exhausting labour 
j of body or mind, the debility brought on by mercury, bad food and 

foul air, grief, care, and other depressing moral causes — all these 

are circumstances which, generally speaking, render fever exceed- 
| ingly dangerous. Inhabitants of towns are worse off in this respect 
j than those who live in the country : this is a fact which has been 

well established. 

Let us now enumerate briefly the symptoms of typhus, arranging 
j them in separate groups, according as they appear in the nervous, 
| respiratory, or digestive systems. First, with respect to the nerves, 
j We observe in typhus a remarkable prostration of strength, and it 
I has this peculiarity in it, that it cannot be referred to a local cause, 
This is what has been termed direct prostration, in contradistinction 
to that which occurs as a consequence of various local inflamma- 
tions. It would not be correct to look upon it in the same light as 
you would the prostration which attends simple primary inflamma- 
tion of the digestive system, or peritonitis ; for we know that bleed- 
ing will remove this, and restore the patient's strength. But the 
prostration of typhus cannot be removed in this way, for it exists 
generally without any perceptible local cause to account for it. We 
have, in the next place, agitation, anxiety, and loss of sleep — a 
remarkable and very unfavourable symptom ; so unfavourable is it 
that, when present, though ail the other symptoms may be trifling 
and free from danger, the chances are often against the patient ; 
whereas, if he sleeps well, the case will very seldom go on badly, 
even though there may be other circumstances in it of a very 
threatening character. We next meet with the different varieties 
of delirium, furious excitement of the brain, or low and quiet mut- 
tering ; then the symptoms connected with the muscular system — 
as floccitatio, subsultus iendinum, pains and spasms in various 
parts of the body, tremors, and paralysis of the sphincters. Now, 
j with respect to the circulation, I told you that, in the commence- 
ment of the disease, we frequently observe an excitement of the 
heart and arterial system simulating the phenomena of active in- 
I flammation. In the advanced stage this disappears, and we have a 



460 



STOKES'S THEORY AND PRACTICE. 



weak and jerking action of the heart, with a feeble irregular pulse, 
which can be compressed by a slight touch of the finger. In some 
cases, where the pulse is naturally irregular, the effect of fever is to 
render it irregular : this is a curious circumstance, and you should 
not neglect inquiring into it. Another remarkable symptom is, 
that you may have a very obvious disproportion between the action 
of the heart and the pulse ; this is most commonly a sign of disease 
of some internal organ. With respect to the state of the blood 
itself, I do not intend to make any particular observations. We 
know almost nothing on this very interesting subject. All we can 
say is, that the blood is altered in its condition ; but what the nature 
of that alteration is, we know not. Notwithstanding all that has 
been written on the subject, there has been as yet no valuable indi- 
cation, no practical improvement, founded on the state of the blood 
in fever.* There can be no doubt, however, that the condition of 
the blood (if known) would furnish a most important link in the 
chain of phenomena, and would be productive of a more certain 
and successful treatment. Still it is only a link, and the treatment 
of fever will still continue to partake of a more or less empirical 
character, as long as w r e remain ignorant of those profound lesions 
of innervation, with which it appears to be so intimately connected. 

When we turn to the respiratory system, we find typhus present- 
ing here also a very numerous and important group of symptoms. 
In some cases we have hurried breathing, with cough, and signs of 
organic lesion of the lung ; in other instances the breathing is 
accelerated, but we are not able to detect any appreciable lesion. 
Here we have a purely nervous dyspnoea ; in the former case we 
have it coexisting with disease of the lung, which can be detected 
by the stethoscope. Hurried respiration is an unfavourable symptom 
in fever. It points out either an organic affection of the lung, 
or a sympathetic excitement. Hurried respiration, without pulmo- 
nary disease, is an anomalous symptom, and all such are to be 
looked on with suspicion. We have sometimes the symptoms of a 
general affection of the respiratory system — cough, dyspnoea, livid- 
ity of countenance, and bloody expectoration. There is nothing 
more common in typhus than catarrh, or congestion of the lungs, 
or pneumonia. A great many fever patients die of extensive but 
latent and neglected bronchitis. The patient may go on for days 
and weeks without presenting anything capable of arresting the 
attention, or exciting the suspicions, of the mere symptomatologist ; 
they will die with tracheal rattle, and, on dissection, the whole 
bronchial mucous membrane will be found in a state of intense in- 
flammation. 

When we come to the digestive system, we find numerous mor- 
bid alterations. The lips are dry and chapped ; the gums red, dry, 
and covered with an adhesive mucus; the teeth crusted with a 

* [This assertion admits of being modified; but just now, I have neither time 
nor space for introducing the numerous details which would be requisite in the 
argument. See Magendie and Stevens, passim, on the Blood. — B.] 



TYPHOUS FEVER. 



461 



peculiar sordes ; the tongue in some cases natural, in others appear- 
ing as if it had been dried and then glazed over; in some covered 
"with a dirty white mucus towards the centre, and clean towards 
the edges and tip ; sometimes its mucous papillae are enlarged, red, 
and prominent ; while, in other cases, it is of a dark brown or black 
colour, its upper surface chapped and inclined to bleed, and its mus- 
cular functions impaired, so that the patient is unable to put it out 
when desired. Then we have thirst, nausea, vomiting, and hiccup. 
In some cases the desire is for cold drinks, in others for hot, and 
occasionally there is no thirst; and the patient drinks only when 
he is requested, and then swallows merely what is sufficient to 
moisten the mouth and fauces. In some cases the fluid ejected 
from the stomach is of a bilious character; in others it is dark, or 
like coffee-grounds. The evacuations from the bowels present a 
very remarkable variety. They may be thin and liquid, or solid 
and figured ; they may be clay-coloured, brown, or black ; and they 
may be passed at considerable intervals of time, or they may be fre- 
quent and harassing. Generally speaking, they are liquid, of an 
unhealthy colour and consistence, and have a peculiar and very 
offensive odour. Obstinate constipation may be met with, but this 
is very rare, and in the great majority of typhous fevers there is 
rather a tendency to diarrhoea. You will have eructations, borbo- 
rygmi, and tympanitis. You may also have jaundice, and this is 
generally to be considered as a bad symptom in fever. 

In order to get an accurate idea of these symptoms, you must 
proceed analytically — you must pass in review the cerebral, respi- 
ratory, circulating, and digestive systems — and see how far the 
symptoms can be connected with actual disease of the three great 
cavities. 



LECTURE XLI. 

Nervous symptoms in typhus — Uncertainty of development — Opinions of Dr. Clutter- 
buck — Unfrequency of lesions of the brain in typhus — Occurrence of all nervous 
symptoms, independent of any appreciable symptoms of the brain — Nature and 
treatment of headache in fever — Delirium, researches of Louis on — Its treatment in 
early and advanced stages of fever — Pathological state of the brain in delirium — Use 
of wine and opium — Dr. Graves's remarks on — Nature of adynamia — Principles of 
treatment of the local inflammations in fever — Errors of the school of Broussais on 
this point — Use of stimulants at certain stages. 

At my last lecture I enumerated the symptoms of typhus, which 
are referable to lesions of the nervous system. The principle of 
these are the occurrence of headache, the different varieties of 
delirium, coma, spasms, subsultus tendinum, and various lesions of 
sensibility. Now, you are all, I believe, aware that the followers 
of Clutterbuck place the seat of fever in the brain, or, in other 
words, they look upon fever as being symptomatic of inflammation 
of the brain. 

This doctrine has acquired a considerable degree of interest, 

40 



462 



STOKES'S THEORY AND PRACTICE. 



from the circumstance of being supported and put forward by such 
high authority, and is therefore entitled to our notice. It must, 
however, be admitted, that it does not rest on a very secure basis, 
for it has been contradicted by the results of the recent investiga- 
tions with respect to the pathology of fever. These investigations 
prove, that lesions of the brain are, in their nature, analogous to 
those of other parts, and can no more explain the phenomena of 
typhus than similar affections of the lungs, or digestive system. It 
has been shown, in the first place, that lesions of the brain (which 
are supposed by Clutterbuck to be the cause of fever) are by no 
means constant in their appearance; that there is the most remarka- 
ble variety in their seat and extent ; and that the appearances, on 
dissection, do not correspond with the symptoms observed during 
life. If we were to consider fever as symptomatic of disease of the 
brain, we should always expect to meet with lesions of the cerebral 
substance under such circumstances, just as we find proportional 
lesions of the lung in the fever of pneumonia, or of the digestive 
system in that of gastro-enteritis. Even in cases where these 
lesions of the brain are found to exist, we do not find that they are 
in proportion to the symptoms, for we may have severe delirium 
and headache in typhus with slight cerebral lesion, and, on the 
other hand, we may have extensive organic disease of the brain 
with a fever, in which the nervous symptoms are but little marked. 
Here, then, we have a character absent which should necessarily 
exist, if typhus was symptomatic of disease of the brain. Thirdly, 
the symptoms, referable to mere irritation of the nervous system, 
independent of typhus, have not the initiative, for we frequently 
observe the symptoms of typhus to precede those which belong to 
irritation of the brain. A patient in typhus will go on for days 
without exhibiting any symptoms of cerebral irritation, and then, 
perhaps, towards the termination of his illness, will get symptoms 
of disease of the brain. But they are not the first link in the chain j 
of morbid phenomena. Again, in cases presenting a similarity, 
nay almost an identity, of symptoms, you will meet with the greatest 
possible variety in the nature, seat, and extent of the organic altera- 
tions. It has been farther shown that, with the same amount of 
nervous symptoms, with symptoms perfectly alike in their nature, 
intensity, and duration, we shall find one class of patients present- 
ing remarkable lesions, and another class with none at all. Lastly, 
we meet with the same state of the brain in cases where no typhoid [ 
symptoms existed, as in those where all the characters of typhus 
were distinct and prominent. 

Now, if we admit the foregoing facts, and I think they cannot be 
denied, we must reject the theory of Dr. Clutterbuck. The lesions 
of the brain are by no means constant in typhus; the symptoms 
observed during life do not correspond with the phenomena of dis- 
section ; we may have extensive organic changes with modified 
symptoms of typhus, and severe typhus with slight organic change; 
and we may have, in patients presenting similar symptoms, great 



I 



TYPHOUS FEVER. 463 

organic changes or none at all. The conclusion which has been 
come to by the most eminent pathologists of the present day on this 
subject is, that, in fevers of an essential type, there is no single 
nervous symptom which may not, and does not, occur independently 
of any appreciable lesion of the brain, nerves, and spinal cord ; that 
the state of the nervous centres, after death, cannot explain the 
symptoms during life, and that the nervous symptoms, in particular, 

j cannot be referred, in many instances, to any known organic altera- 

\ tion of the brain.* 

This is a conclusion which may appear humiliating, and you 

I may think that it depreciates medicine by representing it as obscure, 

. perplexed, and deficient. This, however, is not the proper way of 
considering the matter; you are only to inquire whether it be just 
and well founded or not, and then to steer as well as you can. We 
cannot say anything certain with respect to the nature of these and 
various other symptoms unconnected with any appreciable lesion 
of the nervous system; we merely observe them as facts, and find 
that they square with experience. Experience has shown, long 

! since, that these symptoms frequently subside under treatment 

! which could not be employed if they depended on inflammation. 
How could we explain the disappearance of delirium, under the 
use of opium and wine, or the removal of spasms and subsultus 
tendinum by stimulants, if they depended on active inflammation 
of the brain or its membranes? This is another fact which tallies 
exactly with these already mentioned, and showing that the nervous 

j symptoms of typhus are frequently unconnected with inflammation 
of the brain. 

One general observation may be made with respect to the nervous 
symptoms of fever, that the greater their number and intensity are, 
f the more unfavourable is the prognosis to be. I may here mention, 
that the worst description of nervous symptoms are persistent sleep- 
lessness, constant headache, violent delirium, subsultus tendinum, 
and coma. All these point out profound lesions of innervation, 
and are met with in the worst cases of typhus. They do not point 
out the existence of extensive organic derangement of the brain, or 
that you should treat the case by means adapted to deplete the head, 
but that the fever is of a severe character, and that the shock which 
the system has received is likely to endanger life. Headache is one 
of the most constant symptoms of fever. It is sometimes partial, 
sometimes general; it may be more severe at one time than at 
another, or in one part of the head than the rest, and it may be 
dull, acute, or pulsative. It may or may not be accompanied by 
other symptoms, such as heat of the head, throbbing of the arteries, 
j and the different varieties of delirium. In cases of fever where 

* [Still, it is well to remember that in ramollissement or softening 1 of the brain, as 
described in my addition to a preceding- lecture, we meet with the characteristic 
symptoms of typhus, and that a person whose brain has been long over-excited is 

j prone to typhus if other common causes of fever, such as want of rest, deficient 

i food, and confined air be in operation. — B.] 



464 



STOKES'S THEORY AND PRACTICE. 



there is sympathetic headache, without any other sign of cerebral 
irritation, we are not at all warranted in looking on the case as one 
of disease of the brain. With other symptoms it may, and, conse- 
quently, under these circumstances should command our attention, 
but alone it is to be looked upon as one of the general symptoms, or 
as symptomatic of some of those secondary affections which occur 
in the course of fever. When it is symptomatic, it is most gene- 
rally connected with irritation of the digestive tube. There is 
nothing more, common than headache in gastric fever, and you 
will constantly- see this headache disappear after the application of 
leeches to the epigastrium. This I have witnessed, not in one, but 
in many instances. 

Now, with respect to the treatment of the headache of fever, I 
may observe, that it must be more or less modified by circumstances. 
In mild and simple cases, where the pain of the head is not very 
severe, you may be content with cold applications, which you will 
commonly find to answer very well, particularly where the head- 
ache is accompanied by heat of the scalp, and throbbing of the 
arteries. You will also find the warm foot-bath of service, and 
you may, if necessary, increase its efficacy by the addition of 
mustard. Where the headache resists this treatment, you must 
have recourse to leeching the temples and behind the ears, shaving 
the head, and applying cold or iced lotions. Now it might be 
urged here, that if the best mode of relieving headache is found to 
consist in the application of leeches and cold lotions to the scalp, 
are we not justified in concluding that the symptoms, in these 
instances, are to be looked upon as depending on inflammation? 
I have stated to you, when lecturing on diseases of the brain, that 
headache was not to be considered as connected in all, or even 
many cases, w 7 ith arachnitis ; and besides, it does not follow that 
the symptoms must depend on inflammation, simply because they 
have been relieved by antiphlogistic treatment. What does the 
occurrence of pain in the head prove? Nothing more than this, 
that there is an excited condition, a deranged sensibility of the part 
affected. This derangement of sensibility may be accompanied or 
not by organic disease ; but wmether it is or not, experience has 
shown that it may be relieved by the use of local antiphlogistic 
means. I think you may lay this down as a rule, with respect to 
the pain of the head in fever, that where you meet with headache 
or delirium, and find them connected with other symptoms, indi- 
cating a decided affection of the digestive system, you should seek 
for the cause of the headache in the sympathies w 7 hich attend irrita- 
tion of the gastro-intestinal surface, and direct your plan of treat- 
ment accordingly. If a patient, labouring under gastric symptoms, 
as red tongue, epigastric tenderness, swelled belly, and diarrhoea, 
complains of pain in the head, you may be pretty sure that the 
headache proceeds from sympathy, and that it will be most effectu- 
ally relieved by leeching, and other means calculated to relieve 
gastric irritation. There are two reasons for this : of all the second- 



TYPHOUS FEVER. 



465 



ary irritations of fever those of the digestive system are the most 
common ; and they are, in the majority of cases, productive of more 
or less functional derangement of the brain, with which the gastro- 
intestinal mucous membrane is linked in the closest sympathy. I 
have seen cases of fever where the patient complained of bad head- 
ache, and where the symptoms were combated unsuccessfully from 
day to day by the application of leeches to the head, and yet I have 
[ seen complete relief obtained by putting a few leeches to the 
j epigastrium. If, therefore, you find, in cases like this, pain on 
pressure, tympanitis, diarrhoea, thirst, and other signs of irritation 
of the digestive tube, you will direct your attention to the belly, 
and see whether the headache may not be removed by means 
adapted to subdue gastric irritation. What I wish to impress on 
you is this, that secondary gastric disease will produce headache, 
and that this may be removed by applying leeches to the belly. 

We now come to speak of a very important symptom in fever — - 
delirium. I believe I may here assert that the same pathological 
observations apply to this symptom as to headache, and that, taken 
alone, it cannot by any means be looked on as a decided indication 
: of actual organic or inflammatory disease of the brain. Before I 
enter on the subject of delirium, I wish to make a few remarks on 
the occurrence of hysterical symptoms in fever. In some persons, 
you will find that, at the commencement of fever, fits, like those of 
hysteria, will come on, and this may happen even in the case of 
robust men. One of the worst cases of fever I ever saw, was 
! ushered in by these symptoms. The patient had violent fits of 
laughing, crying, and other symptoms of an hysteric character, and 
these were succeeded by profound typhus. Indeed, the complica- 
tion of hysteria may be looked upon as favourable in all cases 
except fever ; but the occurrence of hysterical symptoms, at an 
early period of fever, affords grounds for making a bad prognosis. 

In fever, we meet with two kinds of delirium — the violent, and 
the low muttering delirium. The high and violent delirium is a 
disagreeable symptom, from the unmanageable state of the patient, 
and the difficulty of doing anything for him. It is most commonly 
observed in the commencement of the disease, whereas the low 
muttering kind is generally observed towards the termination. 
This is the most usual way, but sometimes the reverse takes place ; 
and when this occurs, it is to be looked on as dangerous, on this 
principle, that any departure from the ordinary course of things is 
unfavourable, and gives cause for a bad prognosis in fever. Thus 
the occurrence of low muttering delirium in the commencement, or 
of the violent kind towards the termination, of the disease, is always 
| alarming. Low delirium is most frequently observed towards the 
, close of fever, and we find it always accompanied by other symp- 
! toms, indicating a low and prostrated condition of the system, as 
j subsultus tendinum, picking of the bed-clothes, involuntary stools 
| and urine, hiccup, and cold extremities. 

Let us consider how far we are to consider this symptom as con- 

40* 



466 



STOKES'S THEORY AND PRACTICE. 



nected with actual disease of the brain. Louis, who has devoted a 
considerable share of his attention to this point, has examined care- 
fully the state of the brain in twelve fever patients who had little 
or no delirium, and in twelve others, who died with violent delirium, 
and the following are the results of his experience. In the first 
table he places those who had no delirium : and here we find, that 
in four cases there was some redness of the cortical substance of 
the brain; in one, inflammation of the optic thalamus; in one, 
slight softening of the brain ; and in the remaining six, the cerebral 
substance was quite healthy and normal. Now, in the cases where 
violent delirium was present, the following circumstances were ob- 
served. In five cases the morbid appearances were slight, there 
being some redness and vascularity of the cortical substance, but 
no more; in one, there was slight ramollissement ; in one, livid 
injection of the brain and its membranes; in the remaining five, 
the substance of the brain was of a natural colour and consistence, 
and appeared to be quite healthy. Now, in these two tables, you 
will observe that the difference in the morbid appearances is ex- 
tremely slight, and that the presence or absence of delirium seems 
to have very little connection with the perceptible state of the brain. 
In those cases where there was no delirium, we find four patients 
presenting redness and vascularity of the cortical substance ; in 
those which were attended with violent delirium, we find five 
patients similarly circumstanced. In the cases without delirium, 
there was one with inflammation of the optic thalamus, and another 
with ramollissement ; in those where violent delirium prevailed, 
there was one with ramollissement, and another with dark venous 
congestion of the brain and its membranes. In the first table, 
where delirium was absent, we find six cases in which the brain 
was, to all appearance, healthy and normal ; in the second table 
we find five cases similarly circumstanced. Recollect, too, that 
these observations were made by one of the most accurate patho- 
logists in the world ; a man who had no theory to support, who 
merely records what he has seen, and whose statements are there- 
fore entitled to the most complete credence. With respect to in- 
duration of the brain, M. Louis remarks that he has met with it in 
two; instances of fever; in one, the patient was delirious; in the 
other, the mental powers were unaffected. In the Clinique Medi- 
cate of M. Andral, we find that he has observed induration of the 
brain to be connected with stupor and coma. Thus we see that in 
one case this state of the brain is found in connection with delirium, 
in another with stupor, and in a third with no appreciable lesion of 
the intellectual faculties. The conclusion, then, which we must 
come to is, that inflammation of the brain does not necessarily 
imply delirium, nor does delirium imply any certain disease of the 
brain. 

In the foregoing tables, we have a healthy state of the brain with 
delirium, and a morbid state without, it. Observe the practical de- 
duction to be drawn from this. You might suppose that you could 



TYPHOUS FEVER. 



467 



draw no conclusion from this, which would not have a tendency to 
embarrass your practice, and depreciate the value of medical 
j science. This, however, is not the fact. The conclusion is an 
obvious and a just one, that, in the treatment of a case of delirium, 
we are not to expect that we shall be always able to remove this 
symptom by treatment calculated to relieve inflammation, because it 
I may occur with or without disease of the brain. Whenever you 
| meet with a case of delirium, you should carefully investigate its 
I nature and origin, as far as you possibly can, and if it be probable 
I that lesion of the brain is going on, you should direct your treat- 
! ment to the head ; but if it be merely sympathetic, you must look 
I for its source elsewhere, and regulate your treatment accordingly. 
You cannot always relieve delirium by antiphlogistic means, di- 
rected to the head. This is an undoubted fact, and squares with 
what has been stated with respect to headache, for we find that 
delirium is frequently removed by measures which would be quite 
inadmissible if it depended on actual inflammation of the brain. In 
all cases of febrile delirium, where it is accompanied by pain of the 
head, heat of the scalp, throbbing of the arteries, and other signs 
of determination of blood to the brain, you should not neglect the 
employment of local depleting means. For this purpose, you may 
I use with great advantage the cold afTusion, as recommended and 
practised by Dr. Abercrombie. I have seen patients who were for 
nights without sleep, and in whom the delirium was so uncon- 
trollable that the strait waistcoat was necessary, and I have ob- 
! served that those persons slept soundly and tranquilly after the cold 
affusion. In cases of high delirium with strong "reaction, the use 
of blisters has been recommended. This practice appears to me to 
be questionable and hazardous, and I feel convinced that they very 
often do mischief. A much better practice is that of applying sina- 
pisms to the feet. The strait waistcoat is a measure very frequently 
adopted in the treatment of delirium, but it is one which you should 
be cautious in employing. It is too generally resorted to from ap- 
prehension on the part of the attendants, and is continued through 
mismanagement. In Dr. Cheyne's valuable report on the epidemic 
fever of Ireland, he remarks, that some patients have perished 
from exhaustion in struggling with their attendants, or in endea- 
vouring to free themselves from the restraint of a strait waistcoat. 
If a patient gets out of bed and walks about the room, there is 
not the slightest risk of his receiving any injury, provided he be 
properly covered. When he endeavours to get out of bed, the 
nurse should calm him if possible, and, if he perseveres, use her 
; authority over him, but never resort to violence. She should even 
I permit him to put on his clothes, sit on the side of the bed, or walk 
I about the room, and wait until the violence of the delirium abates. 
This generally occurs in a short time, and the poor patient becomes 
quite amenable. Such are Dr. Cheyne's views. I believe, firmly, 
that the strait w T aistcoat is too often abused. Coercion should be 
used only in extreme cases, and where there is danger of life ; and 
it should be dispensed with on the first opportunity. 



468 



STOKES'S THEORY AND PRACTICE. 



In the advanced stage of fever, even where delirium is present, I 
believe we may often give wine with advantage. I have seen the 
tongue, which was dry and black, or red, become pale and natural 
under the use of wine, opium, and other stimulants. This tallies 
exactly with what I mentioned as to the tongue being rather an 
index of the state of the whole system, than of any particular 
condition of the intestinal canal. With respect to the use of wine, 
Dr. Graves remarks, that it is a common opinion that wine should 
not be allowed while the patient's eyes are red and suffused. He 
is of a different opinion, and thinks it may be often given with 
safety and advantage even in this state. " It should be borne in 
mind," says Dr. Graves (and this is important), " that want of sleep 
will make the eyes red and suffused ; and this being very common 
in fever, it cannot be brought forward as an argument against the 
use of wine. Neither does hot skin contra-indicate the use of wine, 
particularly when there is at the same time a tendency to coldness 
of the extremities." Now, to come to the subject of delirium, so far 
as this is connected with giving wine and stimulants, or withhold- 
ing them, Dr. Graves thinks that when the delirium is violent, 
wine should not be given. I would modify this assertion, and say, 
that it should not be given in the delirium which comes out at an early 
period of fever ; but in the advanced stage I have seen it do good. 
The patient may be irritable, restless, and delirious, and yet in a 
state which demands the use of wine and opium. You will find 
patients in the advanced stage of fever talking incoherently, and 
incapable of giving direct answers to your questions. This state 
of mind is frequently accompanied by an anxiety about their ill- 
ness, and want of sleep. Now, to procure sleep, and remove the 
delirium, you will have recourse to the use of wine and narcotics. 
"Headache," says Dr. Graves, "is, at any period of fever, a bad 
circumstance ; for it does not allow the patient any sleep. Now, 
we must, in the first place, endeavour to remove this symptom by 
depleting the head, and by purgatives. These measures frequently 
succeed, but sometimes they fail, and we cannot pursue this line of 
treatment any farther. (This is the case to which I have already 
alluded.) In this case," says he, " we must prescribe an opiate to 
procure sleep, and from this sleep the patient often awakes much 
improved. Before you employ the opiate, you may apply a blister 
to the head." Much benefit may be derived from the use of the 
common starch injection with tincture of opium. Thirty or forty 
drops of laudanum, in two or three ounces of the mucilage of 
starch, is a very good way of employing opium to procure sleep in 
fever. The general rule with respect to the use of opium is this : 
Where you have nervous symptoms remaining after treatment 
calculated to remove inflammation, or where they have occurred 
unaccompanied by any signs of inflammation of the brain — in 
these cases I feel no doubt that opium may be employed with safety 
and success ; in fact, that it is the best means you can adopt. Ob- 
serve, all that I now state is founded on facts, and independent of 



TYPHOUS FEVER. 



469 



any theory. You will observe, too, that it squares with the patho- 
logy of fever given in a former lecture — namely, that we are to 
look upon it as a general affection of the whole system ; and that 
the presence of any one single symptom does not necessarily imply 
the existence of local inflammatory disease. There is one practical 
remark with respect to local inflammation which I have already 
made, but I shall here beg leave to repeat, as it is connected with 
the point in question. When we compare the three great cavities 
with respect to the comparative frequency of inflammatory disease 
observed in them, we find that the account stands as follows : — 
local inflammatory disease is most frequent in the belly, next in the 
chest, and lastly in the head. We much more frequently meet 
with organic affections of the digestive system in fever, than of the 
pulmonary and of the pulmonary than of the nervous. 

In the advanced stage of fever, we have often to combat with a 
very distressing symptom — namely, coma. The patient lies in a 
state of lethargic stupor, and cannot be roused, or if he exhibits any 
signs of consciousness, it is only for a moment, and then he relapses 
again into the same stupid state. This is a bad symptom, but not 
a fatal one, if it be properly managed. What seems to answer best 
is, keeping the head cool, and using counter-irritation. These two 
measures may appear inconsistent with each other, but they are not 
really so. Some of the worst cases of febrile coma, which I have 
seen recover, were those in which blisters were applied to the back 
of the head, or vertex, or nape of the neck, the rest of the head 
being kept cool. In addition to these measures, you may employ 
counter-irritation to the extremities with advantage. You will see, 
in the works of Lallemand and Mackintosh, some very remarkable 
cases of coma, where the patient was, as it were, snatched from the 
jaws of death by pouring boiling water on the extremities, at the 
same time that the head was kept cool. In the advanced stage of 
fever, where the skin and extremities are cool, the existence of 
coma does not contra-indicate the use of wine. You may also 
employ rnusk in doses of ten or fifteen grains every third hour, 
either alone, or in combination with camphor, or carbonate of 
ammonia. These, with blistering the head and keeping up coun- 
ter-irritation in the lower extremities, are the principal curative 
means used in the treatment of coma. I shall conclude this lecture 
with some observations on adynamic fever. Whenever you meet 
with this remarkable prostration of strength, it will be necessary 
for you to inquire carefully into its nature. You must here bear 
in mind two propositions which should never be forgotten — first, 
that the adynamia may be secondary, and produced by visceral 
lesions, for the removal of which antiphlogistics maybe necessary ; 
and, secondly, that it may exist as a consequence of the morbid 
state of the whole system, and independent of any decided local 
inflammation. The first of these is called false, the second true, 
adynamia. One of the most important questions in fever is con- 
nected with this point, and I beg your particular attention to it. It 



470 



STOKES'S THEORY AND PRACTICE. 



was long taught, and is to a certain extent still believed, that fever 
is a disease of debility ; and hence all the phenomena indicative of 
this debility were treated by stimulants; and it is melancholy to 
reflect that, even at the present day, hundreds of persons are sacri- 
ficed at the shrine of this dogmatism. Now when you recollect 
that fever most commonly presents a group of local inflammatory 
affections, and that the excess, or extent, or seat of a local inflam- 
mation will produce debility, you will very readily perceive that 
there are two^ causes for the adynamia of fever — one the reaction of 
local disease on the constitution, the other depending on a peculiar 
morbid state of the whole system ; and it is in striking a balance 
between these two causes that the judgment of the physician con- 
sists, and it is on the accuracy of his judgment that his success 
will decidedly hinge. In all cases where the prostration is uncon- 
nected with inflammation, or, even if inflammation should exist, 
where antiphlogistics can be no longer employed, you must have 
recourse to the cautious but decided use of stimulants. In some 
cases, particularly where the prostration is not excessive, you may, 
at the same time that you are prescribing stimulants, employ local 
antiphlogistics and counter-irritants with great advantage. When 
I say this, I do not wish you to believe that in treating the inflam- 
matory affections which arise during the course of fever, you are to 
proceed with the same boldness as in original simple inflammation. 
I have before marked the distinction between them. In the second- 
ary local inflammations of fever, where profound lesion of innerva- 
tion and a morbid state of the fluids exist, you should always 
modify the activity of your antiphlogistic measures ; but, on the 
other hand, where the local inflammations are simple, and the con- 
stitution strong, your measures must be prompt and energetic. 
There is one great rule which is applicable to most fevers : — In 
the early stages, antiphlogistics are required ; in the advanced, 
stimulants and tonics. This rule applies not only to fevers, but 
also to most cases of local diseases. In the early stage of fever, you 
may always employ the antiphlogistic treatment so far as regimen, ! 
local depletion, and the prohibition of all stimulants are concerned; 
in the latter periods, where the patient's strength is reduced from 
depletion, extent, or duration of disease, and want of nutriment, 
your object must be to support the strength, and even to give stimu- 
lants. This is the great point which has been overlooked by the 
school of Broussais. They looked upon fever as depending on 
local inflammation, and concluded that stimulants w r ere inadmissi- 
ble at any stage of the disease; and their practice was accordingly 
to continue the use of antiphlogistics throughout the whole case. 
By thus neglecting to support the system, they permitted exhausted 
nature to sink, ignorant of the fact, that while you are taking 
measures to remove local inflammation, you may at the same time 
give nutriment to support strength, and that at certain periods of 
all inflammatory affections, stimulants become antiphlogistics. 
The same thing occurs in local inflammation of a simple and 
original character, as in fever. In healthy inflammation we cannot 



FEVER. 



471 



pursue the antiphlogistic plan all through ; after a certain period it 
loses its effects on the local disease, and it will run the patient down 
if persevered in ; a cure is to be obtained only by the use of stimu- 
lants and tonics. So it is with respect to fever, in the advanced stage 
of which stimulants become antiphlogistics. The great rule, then, 
with respect to the treatment of adynamia isjhis : — First ascertain 
if there is any existing local inflammation, and if it be of sufficient 
; extent and intensity to produce prostration, adopt means to modify 
1 or remove it, as far as your patient's strength will admit; in the 
j next place, if you find no local inflammation to account for it, or if 
| it occurs at an advanced stage, when the powers of life are sinking, 
give wine and stimulants to support nature in the struggle which 
I she is making with disease. In the treatment of the secondary 
local inflammations which arise during the course of the fever, we 
j should always endeavour to moderate the symptoms as far as we can, 
| and gain time. If we can succeed in prolonging life, we give our 
patient every chance for recovery, and allow the powers of nature 
time and opportunity to act. Hence it is that one of the most 
important objects of the physician, in the treatment of the advanced 
i stage of fever, is to prevent his patient from becoming too much 
debilitated. Even though local inflammations should be present, 
yet, if the patient be sinking, and the fever of considerable duration, 
he knows that his only resource lies in judicious stimulation, which 
I fully believe not only acts beneficially on the general fever, but 
also on the local disease, whatever it may be. In all probability, 
the original affections have changed their character, and the irri- 
tated capillaries have passed from a sthenic to an asthenic state ; 
in other words, to a state where antiphlogosis will be, to them, 
insufficient, and, to the disease, dangerous, but where stimulation is 
their cure, and also what nature demands. The great point is to 
know the exact time when we should change our practice. This 
period occurs in all fevers, but the time of its supervention is in- 
finitely various ; and it is in the knowledge of this, as well as in 
striking a proper balance between the dangers to be apprehended 
from local inflammation on the one hand, and constitutional debility 
on the other, that the great nicety of treatment consists. It w r ould 
be impossible to teach this in a lecture ; the only way in which it 
can be learned is by exact and long continued clinical observation 



LECTURE XLII. 

Opium in fever — Dr. Latham's opinion on — Symptoms for the exhibition of opium — 
Affection of the sensorium in fever — Adynamia, consequence of fever — Direct ady- 
namia — Indirect adynamia — Treatment of — Stimulants in fever — Dr. Grant's notions 
of fever — Symptoms of typhus — Catarrh of fever — Opinions of Andral, Louis, and 
Laennec — Bronchitis with fever — Increase of rales on decrease of disease — Affection 
of the gastro-intestinal mucous surface — Symptoms of Pneumonia and bronchitis — 
Pneumonia of fever — Symptomatic affections of the respiratory system in fever — 
Sympathy between the left lung and stomach — Phthisis, consequent of fever. 

I drew your attention, at our last meeting, to the employment of 
opium in the treatment of some of the nervous symptoms of fever 



472 



STOKES'S THEORY AND PRACTICE. 



Before I leave this subject, I wish to lay before you a brief abstract 
of Dr. Latham's opinions on this point. I believe I may say, that 
one of the first persons who proposed and administered opium in 
fever was the celebrated Sydenham. His opinion of it was, that 
after purgation, it is generally productive of good effects. At the 
present day, there is considerable difference of opinion with respect 
to giving opium in fever, but there can be no doubt that it may be 
given with propriety in many cases, and that it has a powerful 
effect in combating some of the worst symptoms of typhus. Dr. 
Latham observes — " In some cases of fever the disorder of the sen- 
sorium keeps pace with that of other parts, and thus the disease 
proceeds until it is somewhat advanced, when the harmony between 
its symptoms is disturbed ; those of the brain outrun the rest; new 
indications of treatment arise, and if the patient can be saved at all 
it must be by opium. Thus the heart and arteries may be full of 
activity, and every symptom in proportion to it. Remedies are 
accordingly addressed to the vascular system, and succeed for 
every purpose they are intended to fulfil, except one. By venesec- 
tion, or topical bleeding, the general symptoms are relieved, and 
each organ loses its peculiar distress, but still the delirium continues. 
With an improved state of the circulation and of other organs, this 
condition of the sensorium remains, and to this subsultus tendinum 
is liable to be added, and the unrestrained passage of the different 
evacuations. 

" In such a case as this," says Dr, Latham, " I have seen a single 
dose of opium, dexterously administered, change the whole com- 
plexion of the disorder in a single night, and place the patient at 
once in a state of safety. Again, I have seen the sensorial affec- 
tions incident to fever, which require opium for their cure, manifest 
themselves in another form. There has been high vascular action 
from the first, and large depletion has been required to subdue it, 
and guard particular organs, and especially the brain, from injury. 
Under such treatment all has gone on successfully, and the patient 
has reached the point of convalescence, when suddenly (the tongue, 
pulse, and all other circumstances continuing favourable) some 
strangeness of manner has arisen, and then the wildest delirium, 
and then the unrestrained passage of the evacuations. I have 
known a transition from such a state of convalescence to such a 
state of peril take place in a few hours ; and I have known the 
patient again brought back to a state of convalescence in twenty- 
four hours, by a moderate dose of opium." 

Three circumstances call for the employment of opium in fever: 
first, where there is persistent watchfulness; secondly, where an 
actual inflammatory condition of the brain existed, and has been 
subdued by proper antiphlogistic treatment, but delirium and other 
nervous symptoms still remain ; and, lastly, where an excited state 
of innervation of the brain exists, without heat of scalp or remark- 
able throbbing of the arteries of the head. 

There is another remark of Dr. Latham, which appears to me 



FEVER. 473 

I 

to be so important that I shall offer no apology for laying it before 
you in full. After observing that the affections of the brain in 
fever are capable of much illustration, from a knowledge of the 
habits and state of health of individuals before they become the 

I subject of fever, he goes on to say — " And here I would make one 
general remark, that, by knowing what a man is, and how he lives 

| habitually, the physician often arrives at a much better judgment, 
and a better treatment of his diseases. It is trying a man's diseases 
by his health, and a most valuable test it is. 

" In healthy and vigorous bodies, there is a certain balance and. 

| regularity of function which, even when disease befalls them, is 
seldom lost ; but their morbid action is still harmonious and propor- 
tional. In them, diseases are often severe, but they are generally 
simple; they often require the most active remedies, but they are 

I generally easy of cure. On the other hand, the weak and valetu- 

i dinary — who, at the best, are full of jars and incongruities — are 
obnoxious to the strangest forms of disease, hard to understand, 
and hard to treat. Now, fever, when it happens to a perfectly 
vigorous and healthy man, is never characterized by any such pecu- 
liar affections of the sensorium as have been mentioned. These 
are incident, according to my observations, to those only whose 
habits and mode of living have been calculated to do an abiding 
injury to the nervous system, and who have been long actually 
suffering from such an injury. Every class of society has furnished 
me with instances of this form of fever, and every instance has con- 

i firmed the truth of the remark. 

"Among the higher and educated classes, there is in this age 
and country a wonderful striving for all the objects of wealth, and 
honour, and power. We need only think upon the strife of poli- 
tics, the hazards of mercantile gambling, and the wear and tear 
of hard professional toil, to see how many there must be who, from 
the common business of life, have derived, both to their minds and 
bodies, new feelings and impulses, and new susceptibilities of dis- 
ease. These susceptibilities chiefly belong to the brain and ner- 
vous system, and they are apt to come forth in frightful activity 
when such men become the subjects of fever. The trouble of 
the brain gets the mastery (as it were) of the disorder of every 
other part. 

" The poor and mean among mankind have the mind over- 
wrought, and the nervous system exhausted, by real calamities, 
just as the high and educated by their more refined ; and thus they 
often claim an unenviable approximation to them in the character 
! of their diseases. 

" To these moral causes," says Dr. Latham, "I will add one 
physical cause which is of most extensive influence — the habitual 
indulgence in spirituous liquors. Individuals who have done a 
permanent harm to the nervous system by the abuse of spirits, do 
never, when they become the subjects of fever, suffer delirium of 
the ordinary kind, in which the brain is excited nearly in the same 

41 



474 



STOKES'S THEORY AND PRACTICE. 



proportion as the blood-vessels, and which, by remedies addressed 
to the blood-vessels, is uniformly controlled ; but they suffer a deli- 
rium in which the brain is actuated disproportionately to, and (per- 
haps) independently of, the blood-vessels ; and, if curable, to be 
cured by opium. This I venture to state almost absolutely and 
without exception." 

I can only state here, that the foregoing eloquent and philoso- 
phical observations are in perfect accordance with what I have 
observed of fever in Dublin. In all cases where the patient has 
been exposed to the depressing effects which high intellectual or 
moral excitement, or the abuse of spirituous liquors, produces on 
the nervous system, you will have, during the course of fever, more 
or less disorder of the sensorium. Here, but particularly if the 
delirium exists independent of any affection of the blood-vessels, 
opium is our sheet-anchor. With respect to the quantity to be 
administered, there are some cases in which it will be necessary to 
feel your way, and indeed I believe that in all cases this is the best 
and safest practice. In place of giving a large dose, as in delirium 
tremens, you commence with a moderate quantity, and if you find 
that this agrees with the patient you can increase it ; at all events, 
by pursuing this plan you will be certain of doing no harm. It 
frequently happens, too, that small doses act very well in this affec- 
tion ; you should, therefore, begin with a moderate dose, watch its 
effects on the patient, and then repeat it in increased or diminished 
quantity, according to circumstances. 

Towards the conclusion of my last lecture, I drew your attention 
generally to the subject of adynamia in fever, and endeavoured to 
show that in most fevers you have to contend with indirect as well 
as direct adynamia. Direct adynamia is that prostration of the 
system which results from the original disease ; indirect adynamia 
is that which is produced by the reaction of the secondary local 
affections. I showed you that in many fevers we had, in addition 
to the debility consequent on an affection of the whole system, an- 
other source of adynamia depending on the local diseases which 
arise during the progress of fever, and that consequently the treat- 
ment of adynamia must vary according to the circumstances under 
which it occurs. I said that the indirect adynamia must be com- 
bated by local antiphlogistic means directed to the inflamed organs, 
but that, in the employment of these means, we should not be so 
vigorous as in cases of idiopathic inflammation, and that the gene- 
ral state of the patient should be always kept in view. You will 
readily assent to this proposition, when you consider that, in idio- 
pathic disease, you have inflammation occurring in a constitution 
previously healthy ; but in the case of local disease supervening 
on fever, in a constitution previously debilitated by general morbid 
derangement. It occurs, in fact, in that state of body in which 
there is a profound affection of the solids and fluids, of circulation, 
of digestion, and of the nervous system. You can, therefore, easily 
understand why the antiphlogistic plan must be employed with 



,1 



FEVER. 475 

| more caution, and followed up with less vigour, in the treatment 
of those secondary affections which arise during the progress of 
fever. 

I mentioned, too, that in most cases of advanced fever, and some- 
times even at an early period of the disease, the employment of 
stimulants may be necessary, even where the fever is accompanied 
by local disease. A period occurs in all fevers (generally at the 

I advanced stage) when general stimulation will be demanded, even 

I though you may at the same time be able to detect local irritation. 
In such cases as these we might say that direct adynamia was pre- 

I dominant, and that, as danger was to be chiefly apprehended from 
this cause, we must meet it with stimulants. You will recollect I 
mentioned, at my last lecture, that a state of the general system and 
of the local disease occurred at an advanced period, to which anti- 
phlogistics were no longer applicable, and in which, by giving 

1 stimulants, we assisted the efforts of nature, and gained time for 
the treatment of the local affection ; in a word, that the formula of 
treatment for most cases of fever was the same as in cases of idio- 
pathic inflammation. In the early period we employ antiphlogistic 
means, both general and local ; in the advanced stage we use stimu- 
lants and tonics. In all cases of simple inflammatory disease, a 
time arrives when you must change your hand, and have recourse 
to an opposite line of practice ; and the same thing occurs with 
respect to fever, whether we view it as an original affection of the 
whole system, or as symptomatic of some local irritation. I showed 
you, too, that you might in many instances combine local antiphlo- 
gistics with a general tonic treatment — the latter to be regulated so 
as to support the patient's strength without increasing the local dis- 
ease. It will often happen, that, in the advanced stage of fever, 
you will meet with enteritis, or pneumonia, or some other local 
inflammation; here, while you are engaged in reducing the local 
inflammatory affection, you may also support the patient's strength 
with light nutritious diet, and even a little wine. In Dr. Grant's 
work on fever there is an important remark bearing on this point, 
which I shall beg leave to quote. " I know," says he, " two phy- 
sicians, both in considerable practice, and both honest men, w r ho 
have constantly treated fever badly from different causes. The one 
never gave cordials, wine, or nutritious food, during the whole dis- 
ease ; the other, after the fourth day, never gave anything else. 
A combination of both these modes, employing each according to 
the circumstances of the case, would be very excellent practice. 
Their error, however, was not entirely the same, nor did the same 
effects result from these opposite modes of treatment. The patients 
treated by the physician who persevered in the antiphlogistic sys- 
tem seldom died, but their recovery was tedious and protracted ; 
those who were treated by stimulants throughout the entire disease 
seldom recovered." Observe how well this agrees with the doc- 
trines I have laid down for the management of fever. The first 
practitioner generally cured his patients, but their convalescence 



476 



STOKES'S THEORY AND PRACTICE. 



was slow and difficult, because he used antiphlogistics too boldly 
and too long. He was ignorant of the fact, that, after a certain 
period and at a particular stage of the disease, antiphlogistics lose 
their efficacy ; and his patients may therefore be said to have reco- 
vered by the unaided powers of nature. He was ignorant also of 
the fact, that, at a certain period of fever, certain conditions of 
innervation exist, in which what are called stimulants have a pow- 
erful effect in removing the disease, even though characterized by 
symptoms which have been termed inflammatory ; while he who 
used nothing but stimulants, being ignorant of the number and 
consequence of the local inflammations, lost his patients by a too 
early and indiscriminate stimulation. 

I shall now proceed with the analysis of the symptoms of typhus, 
and the proper mode of treating them. Having discussed those 
which belong to the nervous, let us now take up the consideration j 
of those which characterize affections of the respiratory, system. 
Before, however, we leave the subject of nervous symptoms, I may 
mention that some researches have been lately made on the state of 
the spinal cord and ganglionic system in fever; but there has been 
no result from these investigations calculated to throw any new 
light on the nature and treatment of the disease. Indeed, it is a 
remarkable fact, that in many instances of fever, remarkable for 
the extent and persistence of nervous symptoms, we cannot detect 
any lesion of the brain or spinal cord. In certain cases it has been 
stated that the sympathetic nerves were found diseased ; but this 
occurs so seldom, and with so little constancy or correspondence of 
the existing symptoms with the derangement of the nerves, that it 
is impossible to establish any connection between lesions of the 
ganglionic system and typhus. 

I believe I may say that a considerable number of cases of 
typhus are either unaccompanied by thoracic symptoms, or, if they 
do exist, they are in general slight and easily manageable. In some 
instances, however, the pulmonary system is severely attacked ; j 
and, in many cases of this description, death is caused by asphyxia 
from exorbitant secretion, brought on by extensive bronchitis occur- i 
ring during the course of fever. There is one general observation, 
which applies not merely to the derangement of the respiratory 
system but also to the morbid changes which may take place in 
any viscus of the body during the progress of typhus ; and this is, 
that the functional derangement observed in each particular organ 
during life is seldom in proportion to the changes discovered after 
death. With symptoms of an apparently trifling character, and by 
no means calculated to alarm, you may, in the case of the lung, 
find after death marks of universal bronchitis, of enormous con- 
gestion, or extensive pneumonia. The same character of insidious 
latency applies to all the inflammatory affections which come on 
during the progress of fever. If we seek for an explanation of this 
fact, we shall perhaps find it in considering that, during the exist- 
ence of fever, the nervous system appears to be labouring under 



FEVER. 



477 



some profound injury; and we know that where innervation is 
injured sensibility is impaired, and hence the symptoms expressive 
of suffering or disorganization are more or less latent. Hippocrates 
observes, in one of his aphorisms, that in cases of severe disease, 
where no pain is complained of, there is disease of the brain ; thus 
accounting for the absence of suffering by referring it to some lesion 

! of the sensorium. 

In speaking of the catarrh of fever, I beg of you to bear in mind 

> that this, like all the other inflammatory affections supervening on 
fever, is to be looked upon as a secondary inflammation.* When I 

! use the term catarrhal or gastro-catarrhal fever, I do not mean to 
express fever symptomatic of catarrh, or of catarrh combined with 
gastritis, but that the catarrh, whether simple or combined with 
gastro-enteric disease, is one of the results of fever. There can be 
no doubt that, in the majority of instances, this is the case. All 

' the arguments which I have adduced, to prove that affections of the 
brain were not the cause of fever, apply also to disease of the lungs ; 

j and we shall find the same thing to hold good when we come to 
the digestive system. The experience of Andral, Louis, Laennec, 
and various British authors who have written on fever, perfectly 
coincides on this point. You will see, in Laennec's work on aus- 
cultation, that he has devoted a good deal of his attention to those 
secondary affections of the lungs which occur during the progress 
of fever. 

Now, in many cases, this bronchitic derangement may exist dur- 
I ing the whole course of the disease without any degree of violence, 
and the patient will recover without having any attention paid to 
it; in fact, many will go through fever with lesion of the bronchial 
mucous membrane so slight as to have no claim to notice. The 
occurrence of an affection of so trifling a character as this is not 
sufficient grounds for altering or modifying your prognosis ; still it 
should always put you on your guard, for it may, in the course 
of six or seven days, become greatly exacerbated, assume a very 
intense character, and even carry off the patient. Whenever, then, 
you discover any increase in the bronchitic symptoms, direct your 
attention immediately to the state of the lung, and be on your guard 
lest the disease should get ahead of you. What we generally ob- 
serve in these cases is, that the patient has some cough, but this is 
neither hard nor troublesome; you can hear now and then a few 
sonorous rales over the chest, but it sounds quite clear on percus- 
sion. Such a case as this, as long as it remains unchanged, is of 
very little consequence. In some instances, however, the affection 
of the bronchial membrane becomes a most formidable symptom : 

* [I have had cases in which the two appeared simultaneously in consequence 
of the patients having got wet by exposure to rain in travelling or labour during 
the latter part of the summer. For the first week the catarrhal symptoms pre- 
dominated, — after which, those of the brain and digestive system acquired the 
ascendancy. These are among the most obstinate and protracted forms of fever 
which we have to combat.— B.] 

41* 



478 STOKES'S THEORY AND PRACTICE. 

the patient has lividity of face, cough, hurried breathing and expec- 
toration, and all his symptoms point out the existence of a very 
extensive disease of the lungs. In other cases, the symptoms of i 
bronchitis may be almost entirely absent; and yet, if you make an 
examination with the stethoscope, you will detect the existence of \ 
a latent but general and intense bronchitis. Here, persons unac- j 
quainted with the stethoscope, and depending on symptoms only, 
may be led into great and fatal errors. Nay, even persons ac- I 
quainted with the use of this instrument may, by neglecting to \ 
make a proper examination, fall into great mistakes. Thus, if you 
apply the stethoscope to the patient's chest while he is lying on his 1 
back and breathing in the ordinary way, all you can ascertain is 
that there is feebleness of respiration, with here and there a sono- I 
rous rale. If you were to content yourself with such an examina- > 
tion, and decide as to the state of the bronchial mucous membrane fe 
from the signs afforded by ordinary respiration, you would be I 
wrong; for, though the rale may be few and scattered during 
ordinary breathing, you will find that when you raise the patient 
up, and make him take a full inspiration, so as to cause the air to ! 
enter the minute bronchial tubes and air vesicles, the rales become 
intense and are audible over a large portion of the lung. You will 
find, also, that the disease generally affects the middle, inferior, and 
posterior parts of the lung, and that it produces here symptoms 
approximating to those of pneumonia. Another curious circum- 
stance connected with cases of this description is, that, according 
as the patient gets better, the rales become louder and more distinct ; 
and here we have the apparent anomaly of an increase of the mor- 
bid sound pointing out a decrease of the disease. This is explained 
by recollecting that, at the height of the bronchial affection, the 
minute bronchial tubes and air vesicles are chiefly engaged : and 
as from the engorgement of the lining membrane, the quantity of 
mucus which fills them, and the feeble state of respiration, the air 
either does not enter into them, or, if it does, only imperfectly, the f 
consequence is that the characteristic rale, or morbid sound, is \ 
scarcely heard. But when the disease is on the decline, and the 
minute tubes become free, the bronchial affection being then chiefly f 
confined to the larger tubes, we can hear the sonorous rale distinctly I 
during ordinary breathing. Many cases of this kind terminate 
fatally. The patient continues in a low adynamic state, with hur- 
ried breathing and lividity of face, for two or three days ; then | 
comes a rattle in the throat, and in the course of ten or twelve 
hours he dies. On dissection, the marks of general bronchitis are i 
evident, and the bronchial tubes are found filled with a sanguino- [ 
lent mucus. In some of these cases, super-secretion from the bron- 
chial mucous membrane sets in with extraordinary rapidity, and 
carries the patient off at once. 

This form of disease is ordinarily coexistent with derangement f 
of the gastro-intestinal mucous surface, and this forms one of the 
most common and fatal varieties of fever in this country. In some 



I 



FEVER. 



479 



I cases the disease predominates in the respiratory, in others in the 
\ digestive, system ; and in some instances you will see a very 
I curious alternation of this predominance of morbid action between 
I the thoracic and abdominal cavities. To-day the breathing is hur- 
I ried, the cough troublesome, the stethoscopic signs well-marked ; 
j in two or three days after, the cough disappears and the breathing 
1 is relieved, but the belly is more swollen and tender, and the tongue 
j has become redder and more parched. Then the abdominal symp- 
I toms will improve, and the indications of pulmonary irritation 
| become again more manifest; and thus, even during the course of 
! the same fever, we may have several alternations of this kind. 
I This complication of disease of the thoracic and abdominal cavi- 
! ties is extremely common in fever; in fact, it may be almost laid 
! down as a general rule, that, in the affections of the respiratory 
j system in fever, there is a complication with disease of the digestive 

tube. Now, you should always bear this in mind, and, when you 
! prescribe medicines to relieve the pulmonary affection, you should 
j take care that they shall not produce irritation of the digestive 

system. 

In most cases of severe bronchial inflammation, you will observe 
more or less lividity of countenance. This is not seen in cases of 
simple pneumonia occurring in fever. Bronchitis has a much 
more powerful effect in producing this phenomenon than pneumo- 
nia, and hence it is that slight bronchitis will cause more lividity 
of countenance than extensive pneumonia. This fact seems to be 
' in accordance with the opinion, that the portion of the lung in 
which the process of aeration is carried on is the bronchial mucous 
membrane, and not the air vesicles. In inflammation of the air- 
cells of the lung we have little or no lividity, but we never see a 
case of extensive bronchitis without it. I may mention here, also, 
that I have seen several cases of bronchitis with very remarkable 
lividity, in which the temperature of the body was above the natu- 
ral standard, thus giving a direct proof that animal temperature 
depends on something else besides the aeration of the blood. 

We come now to speak of the pneumonia of fever. This affec- 
tion may occur under two forms ; that is to say, its symptoms may 
be manifest and prominent, or they may be latent and inappreciable, 
except through the medium of auscultation. Of these forms the 
latter is the most common. You may in typhus have all symp- 
toms present which characterize idiopathic pneumonia — you may 
have hurried breathing, cough, pain in the chest, bloody expectora- 
l tion, &c. — but I believe that, in the majority of cases, the pneumo- 
! nia of fever is more or less latent. It often happens, that, at an 
I advanced period of fever, without any increase of dyspnoea or 
I cough, the patient gets worse; and this change, you may be sure, 
j is indicative of some great visceral lesion. The pulse gets smaller 
and more feeble, and, on making an examination, we generally find 
| the cause to be an extensive but latent pneumonia. Without mani- 
festing its existence by any of the usual symptoms, the disease 



i 

i 



480 STOKES'S THEORY AND PRACTICE. 

comes on insidiously and rapidly ; and, on examining the chest 
with the stethoscope, we hear the crepitating rale over a large por- 
tion of the lung, and the chest sounds dull on percussion to a very 
considerable extent. Observe here the importance of a thorough 
knowledge of auscultation. I think I may safely venture to assert 
that a person, ignorant of percussion and the stethoscope, is totally 
incompetent to undertake the treatment of any case of fever. I 
know it has been asserted, by some authors, that these affections of 
the respiratory system are more of a congestive than an inflamma- 
tory nature. To this opinion I cannot subscribe. We find in such 
cases, on dissection, all the pathological appearances of active in^ 
flammation, redness, thickening, and ulceration of the mucous 
membrane, sanguinolent secretion, congestion, hepatisation, puru- 
lent infiltration, and even abscess of the lung. 

It is a very remarkable circumstance, that the pleura seems, of 
all the pulmonary tissues, to be the least liable to morbid alterations 
in fever. From the details of a great number of modern dissec- 
tions, it appears that, in many cases of fever where extensive 
bronchitis and pneumonia were found to exist, the pleura has in 
almost every instance escaped. If this be true, it would seem to 
point out some difference between ordinary idiopathic pneumonia 
and the pneumonia of fever. In the former, we have generally 
more or less pleuritic inflammation; in the latter, it is rarely met 
w r ith. There is, in most cases of bad fever, an effusion of bloody 
serum into the cavity of the pleura, and the same thing has been 
observed in the case of animals who have been poisoned by the 
introduction of putrid substances into the venis. This leads us to 
the knowledge of a fact connected with the history of typhus, that 
the tissues which are most liable to secondary inflammation are the 
mucous membranes and parenchymatous organs. On the other 
hand, the serous membranes seem to enjoy a comparative exemption 
from active disease. We meet with arachnitis now and then, but 
very seldom with pleuritis, pericarditis, and still more rarely with 
peritonitis. Though you may have extensive pneumonia in the 1 
chest'or enteritis in the belly, you will have no trace of the exist- 
ence of inflammation of the peritoneum or pleura; and there can 
be no doubt that serous membranes are least liable to inflammation 
in fever. We might attempt to explain this, by considering that 
serous membranes possess but very little sensibility and conse- 
quently are less susceptible of irritation. In the healthy state they 
seem to be insensible, and we cannot trace nerves in their substance 
or on their surfaces. This insensibility appears to be one cause of 
their exemption ; another is, that they are supplied with white blood, 
a portion of the circulation which seems to be least altered in fever 
— that which is most effected being the fibrin and colouring 
matter. 

Let us now discuss the symptomatic affections of the respiratory 
system in fever. You may have dyspnoea, hurried breathing, and 
cough, and yet, on examination, you cannot find any distinct signs 



i 



FEVER. 



481 



of bronchitis or pneumonia. You will often meet with symptoms 
of pulmonary derangement in fever, and yet, when you come to 
apply the stethoscope, you find either no sign of disease, or, if there 
be any, quite insufficient to account for the symptoms. Under these 
circumstances, the affection of the chest must be looked upon as 
sympathetic, and the disease which is its most common cause is 
I gastro-enteric inflammation. Here, again, we have another remark- 
I able instance of the value of the stethoscope. Symptoms indicating 
i marked pulmonary derangement exist ; and, if we had not this 
i means of regulating our judgment, w T e should most probably con- 
! elude that there was actual disease of the lungs, and would proceed 
j to treat a sympathetic for a real affection. But, by the aids which 
j physical diagnosis affords, we arrive at a knowledge of the real 
I seat of the disease, and are enabled to direct our curative measures 
! with certainty and effect. But, when I say this, I beg of you to 
1 understand that I do not mean that you should be satisfied with a 
! slight or single examination of the case. It may happen that these 
j symptoms (wholly dependent on sympathetic irritation) may go on 
1 in this way for several days, and then a change may take place, 
' and organic disease of the lung supervene. It is a common, but, 
generally speaking, a true observation, that sympathetic irritation 
j of any organ (when long continued) has a tendency to terminate in 
actual disease. The circumstances which favour this change are, 
j first, the excessive violence of the functional derangement, and, in 
I the next place, its long continuance. You must be, therefore, on 
1 your guard, and examine the chest from day to day; and, if any 
signs of inflammation appear, meet them with promptitude, and 
you will generally succeed in averting dangerous consequences. 
There is another circumstance worthy of remark. If you have 
sympathetic irritation of any organ without fever, the chances are 
that it may go on for a long time without producing any bad 
effects; but, if it be accompanied by fever, there is a greater proba- 
bility of its being converted into organic disease. This should 
make you cautious in cases of sympathetic affections of the lung 
in fever. As far as my observation goes, I would say, that, when 
disease of the gastro-intestinal surface is followed by an affection 
of the lung, the morbid action generally takes place in the left 
lung and in its lower lobe. There seems to be a greater sympathy 
between the left lung and the stomach, than the right, and you 
should therefore direct your attention particularly to the left side 
of the chest. It is a curious fact, that inflammation of the lower 
| part of the left lung is very frequently connected with pericarditis 
; and gastritis. There seems to exist a very remarkable sympathy 
! between organs on the same side of the body. This is a curious 
| fact, and demands some other explanation besides that which was 
given by Mr. Hunter, who attributed it to contiguity of position. 

The last subject to which I shall allude is, that a liability to 
chronic disease of the lung very frequently occurs in those cases of 
pulmonary derangement during fever, and this is apt to came on 



j 



482 



STOKES'S THEORY AND PRACTICE. 



after the symptoms of the original attack have subsided. In several 
instances of this kind, you will observe that the bronchial symp- 
toms which are present in fever, and which do not excite any 
degree of alarm, will very often, on the subsidence of the fever, 
assume a more threatening character, and pass into phthisis. There 
is something in the course of fever which has a strong tendency to 
develope tubercles in persons who are in any way liable to them. 
We have had numerous examples of this fact among the fever 
patients treated in the Meath Hospital. Such of you as are anxious 
for more detailed information on this point, I would beg leave to 
refer to some researches of mine on this subject, published in the 
Transactions of the College of Physicians. In the epidemic of 
1826, it was a common thing to see our patients, after recovering 
from fever, attacked and carried off by phthisis. This form of 
phthisis ran through all the usual stages, from the recent formation 
of tubercles up to the formation of cavities, and was generally very 
rapid in its progress. In one case the patient died of consumption 
in seven days after the subsidence of the fever. 

If, then, you find towards the close of fever that the patient has 
dulness under one or both clavicles, with feebleness of respiration, 
and the other signs of phthisis, you should be on the look-out for 
tubercles. If you find the dulness increase every day, you may 
be pretty sure of the occurrence of tubercular development. On 
the other hand, you should remember, that of all the cases in which 
bronchitis is most likely to simulate phthisis, it is when it comes on 
after fever. A patient, getting an attack of bronchitis after fever, 
will, in that weak and debilitated condition, exhibit in a short time 
all the symptoms of phthisis. He will have bad cough, laborious 
breathing, great emaciation, and well-marked hectic ; yet, in many 
instances, I have seen such patients recover under a judicious treat- 
ment. 

To-morrow we shall again take up the consideration of the pul- 
monary system ; and this, with some observations on the secondary 
lesions of the gastro-intestinal surface, will conclude what I have 
to offer on the subject of fever. 



LECTURE XL11I. 

Peripneumonia des agonizans of Laennec — Congestion of the lungs from position — 
Avenbrugger's opinions on — Precaution of Boyer — Importance of position in typhus 
— Treatment of catarrh and pneumonia in typhus — Principles of treatment — Manage- 
ment of excessive secretion — Employment of emetics — Use of sulphate of quinine 
and opium in injections — Typhoid pneumonia — Gastric symptoms in fever — Brous- 
sais' physiological theory — Brown's sthenia and asthenia — Remarks of the physiologi- 
cal school — Different treatments of fever. 

Before we proceed to the consideration of the abdominal symp- 
toms of fever, there are a few more pulmonary affections on w 7 hich 
I wish to make a few observations. There is one lesion of the 
lung, not unfrequent in this disease, which consists in a congested 



FEVER. 



483 



state of the posterior and inferior parts of the lung, and is chiefly 
observed in persons who labour under great debility, and who have 
lain a long time on their backs. It is of importance to be acquainted 
with this, because there can be little doubt that though in all cases 
it is merely the effect of the fever, it may be, in many instances, the 
cause of death. You can easily conceive that it might be the cause 
of death, when you recollect that extensive congestion of the lung 
will produce asphyxia, by obstructing the pulmonary circulation. 
This affection has got from Laennec the name of peripneumonie 
des agonimns ; but I feel satisfied, that, in giving it this appella- 
j tion, he has taken only a limited view of the matter, for it may 
come on long before the fatal termination of the disease ; in fact, it 
J may occur in all cases where the patient has lain for a long time 
on his back, and where the fluids have undergone any amount of 
morbid change. Indeed, there seems to be some analogy between 
this affection and the discolorations of the skin of the back and 
! nates, which result, in such cases, from a long continuance of the 
j supine position, and which may be observed in many other affec- 
! tions as well as typhus. If you raise a patient in bad typhus, after 
! having been in this posture for a considerable time, and examine 
the postero-inferior part of the chest, you will often find a degree 
of dulness on percussion, and perhaps some crepitus; but if the 
patient continues in the erect posture for a little time, these pheno- 
mena gradually disappear, and the lung resumes its ordinary per- 
meability, except in cases where the congested state has been of 
i several days' standing. Avenbrugger was aware of the occurrence 
of this affection of the lung. In his remarks on the use of percus- 
sion in the exanthematous diseases, he alludes to the occurrence of 
congestion in the posterior part of the lung, before the eruption 
makes its appearance. The celebrated Boyer has also alluded to 
this matter in his works. In giving directions with respect to the 
posture of the patient in case of fracture, he alludes to the proba- 
bility of congestion of the lung from this cause, and dwells on the 
dangers likely to arise from long lying on the back. It would 
appear from some modern researches of M. Piorry, that some 
persons are much more liable to this condition than others, particu- 
larly those who labour under old age, weakness, or disease of the 
heart. 

Now, suppose you have a case of typhus, in which the position 
on the back has been long maintained, and particularly if the 
patient be advanced in life, in a state of great debility, or labouring 
under organic disease of the heart, you should be on the look-out 
i for this congested state of the lungs. In some of these cases it has 
j been found that local bleeding, counter-irritation, and changing the 
, position as much as can be done, have succeeded in removing this 
i condition; but in the vast majority of cases it has occurred in 
| persons reduced to a very weak and exhausted state, and at a 
period when the fatal termination was fast approaching. We can 
! therefore say little or nothing about its treatment. One thing 



484 STOKES'S THEORY AND PRACTICE. 



appears certain, that although we cannot remove this affection 
when once established in the last periods of life, we may do a 
great deal towards preventing its occurrence ; and for this purpose 
nothing is of so much importance as attention to position. We 
know that it is the postero-inferior part of the lung which is sub- 
ject to this mechanical hyperaemia and consequent solidification. 
Now, in the early stage of this affection, and in milder cases we 
observe that this incipient congestion disappears when the patient 
is placed in the erect position, and from this we derive the follow- 
ing indication, that in all cases of typhus, where there is great pros- 
tration of strength, and where there is reason to suspect a dete- 
rioration of the fluids, it is advisable to change the position of the 
patient frequently. You should be careful in making him lie on 
his side, changing his position occasionally from one side to the 
other, and in not permitting him to lie on his back. Four circum- 
stances tend to produce this hypostatic pneumonia : first, lesion of 
innervation; secondly, the change of the fluids; thirdly, position ; 
and, lastly, the want of proper action in the lung ; for when the 
patient is lying on his back, the posterior part of that organ 
expands but little on respiration. If you then place him upright, 
or lay him on his face or side, you get rid, more or less, of the bad 
effects of position, and enable him to counteract the inaction of the 
lung, the full expansion of which seems to be a powerful means of 
relieving this apparently mechanical congestion. In many cases, 
too, I have found that the use of the cupping-glasses over the 
affected position, followed in some cases with a blister, had the best 
effect in removing the affection. In the case of this hypostatic 
pneumonia in fever, it will generally be right, to support the patient's 
strength, to give a little wine, and the decoct, polygalse, with car- 
bonate of ammonia. 

Let us now proceed to the treatment of catarrh and pneumonia 
in typhus. I have already stated that in most of these cases there 
is a complication with disease in the digestive system. Suppose, 
then, you meet with a case of typhus, in which you find the 
mucous membrane of the lungs extensively inflamed, is it advisa- 
ble here to perform general bleeding? Some time ago I was 
strongly opposed to the use of general bleeding in any case 
of this secondary typhoid bronchitis, because we found that in many 
cases it did little good, and in some, by reducing the powers of life, 
seemed to do great injury. Since then, however, I have been less 
opposed to this practice, having witnessed its good effects in cases 
where the disease occurred in persons of robust constitution, at an 
early period of fever, and accompanied by hot skin, quick pulse, 
considerable reactive powers, and great dyspnoea, produced not by 
the supervention of enormous secretion into the bronchial tubes, 
but by their inflammatory condition, which could be ascertained 
by the stethoscope. Dyspnoea depending on inflammation may 
be relieved by bleeding ; dyspnoea depending on excess of secretion 
is not. In the latter the loss of blood will increase the danger of 



FEVER. 



485 



asphyxia, for as the general strength is diminished, the powers of 
expectoration cease, and tracheal rattle comes on. Here we have 
a beautiful practical illustration of the utility and value of the 
stethoscope. 

If, then, you have a case of extensive bronchitis occurring as a 
secondary affection in fever, in a young robust subject, with heat 
of skin, quickness of pulse, considerable powers of reaction, and 
dyspnosa, not produced by over secretion at an early period, you 
will be authorised in taking blood from the system generally. I 
say this, because I have, in several of such cases, employed vene- 
section with the best effects. But, as a general rule, I believe that, 
in cases of pulmonary disease occurring in fever, local bleeding is 
preferable. You will always be able to give relief by leeching or 
cupping the chest ; indeed, I have frequently seen the patient 
relieved by dry-cupping over the thorax to so great a degree that 
I look upon it as one of the most important measures you can 
adopt in the bronchitis or pneumonia of typhus. I have frequently 
removed a degree of congestion sufficient to cause manifest dul- 
ness, by this measure alone. By this proceeding, the congestion 
has often disappeared in twenty-four hours, and with wonderful 
relief to the patient. You may also apply blisters, and these 
valuable agents may be employed at an earlier period than in 
cases of ordinary bronchitis. If the stomach will bear it, you 
may give small doses of ipecacuanha or calomel, and Dover's 
powders. 

Suppose you meet with a case of this kind at an advanced period 
of fever, and find that the patient is very low, has great dyspnosa 
and cough, and that the stethoscope informs you that there is a 
copious secretion into the bronchial tubes. Here you must be 
prompt and decided in the employment of your therapeutic means, 
for you have a very dangerous affection to contend with, and if 
relief be not quickly afforded, the patient will die of asphyxia. 
You must immediately have recourse to extensive counter-irrita-' 
tion, and the use of the decoct, polygalse, with carbonate of ammo- 
nia, and the camphorated tincture of opium; and if the patient's 
strength be much reduced, you must give wine with freedom, and 
light nutritious food. One of the most favourable circumstances 
connected with the use of wine in these cases, is the abatement of 
the frequency of the pulse. Great attention must be paid to the 
temperature of the surface. I have long been in the habit of order- 
ing the patients to be clothed in soft flannel, and I feel certain that 
this measure is one of the utmost utility. If after using wine you 
find that the patient's pulse has come down, you may be sure that 
i it was required, and that it will do good. Sometimes, during the 
I existence of this condition of the lungs, a state of impending suffo- 
j cation will occur, accompanied by tracheal rattle. Here the 
I patient is in danger of perishing from a mechanical cause, and this 
j may happen even at a time when he has not arrived at a state of 
| great debility ; in fact, while his pulse is still tolerably full, and 

42 



486 



STOKES'S THEORY AND PRACTICE. 



his skin and extremities warm. It is in this stage that emetics 
have been recommended. When lecturing on chronic bronchitis, 
I gave the results of my experience on this point, and stated that, 
in many instances, powerful emetics, even though repeatedly 
administered, had failed to act on the stomach. The insensibility 
of the stomach here depends on various causes; on lesion of in- 
nervation, on asthenia of the stomach, produced by determination of 
blood to another organ, and, as some think, on that condition which 
is observed to accompany the want of proper aeration of the blood. 
From whatever cause this insensibility proceeds, we frequently see 
that emetics, which in the ordinary state of the stomach exercise 
their full action, prove inefficient in many cases of this description. 
A scruple of ipecacuanha is given, then an emetic of sulphate of 
zinc, and, when this fails, an emetic of sulphate of copper, and 
these will not only fail in exciting emesis, but may also do a great 
deal of harm. Again, in many cases, even after vomiting has been 
produced, and the patient is, as it were, snatched from the jaws of 
death, we find that the same distressing symptoms return in the 
space of six or eight hours. Another emetic is then administered, 
and relief may be again obtained, but the dreaded state of suffoca- 
tion returns. We had a case in the Meath Hospital, in which free 
vomiting was produced four or five times, and yet the patient died 
afterwards of suffocation from the extent of the effusion into the air 
tubes. To a person who had not witnessed this case during its 
progress, the appearance of the patient after vomiting would not 
appear to indicate anything alarming ; yet the awful state of suffo- 
cation returned again and again, until emetics lost their power over 
the stomach, and the patient died asphyxiated. It is plain that if 
you can produce emesis you gain time for the administration of 
other remedies, and arrest the progress of the disease towards a 
fatal termination. This time, I need not tell you, must be employed 
actively and sedulously in the application of means calculated to 
remove the disease, and subdue the morbid state of the lung ; and 
no one can deny the meed of praise to my enlightened friend, Dr. 
Mackintosh, for his bringing this subject before the profession. 
But it is only one of the many boons his vigorous mind has con- 
ferred upon medicine. In a case of this kind, my colleague, Dr. 
Graves, succeeded in arresting the disease by the application of 
moxa along the course of the eighth pair of nerves, in combination 
with other measures. In a late number of the Dublin Medical 
Journal he has handled this subject. In this paper (to which I 
would refer you) he has proposed the use of sulphate of quinine and 
opium in the form of injection, and gives the particulars of some 
cases of impending suffocation, in which these remedies produced 
very favourable results. He says that tonics and opium exercise 
a very powerful influence in arresting the super-secretion of the 
bronchial mucous membrane, and that it has been frequently ob- 
served in cases of ordinary catarrh, that these remedies, when in- 
judiciously exhibited, have checked the expectoration. Now one 



FEVER. 



487 



great object in this disease is to prevent this excessive secretion 
which threatens life ; and as our remedies for this purpose are, un- 
fortunately, very scanty, any addition must be of great importance. 
Dr. Graves has given the particulars of three cases in which he 
tried opium and quinine in the form of injection. One of his patients 
was a delicate female, who had got a violent attack of influenza, 
followed by enormous effusion into the bronchial tubes. In a few 
I hours her strength became quite exhausted, her countenance as- 
sumed a livid hue, and, to add to her sufferings, she had nausea and 
vomiting. An enema of thin starch, containing ten grains of sul- 
| phate of quinine and thirty drops of laudanum, was ordered to be 
given immediately. Shortly after the use of this, she fell asleep, 
her breathing became less laboured, and she awoke with considera- 
ble improvement in her strength; this patient recovered. Dr. Graves 
next details another case of the same description, where there were 
great debility, alarming dyspnoea, and a sense of impending suffo- 
cation. In this case the quinine and opium were administered as 
before, and the patient recovered. In another case of a patient in 
the Meath Hospital, who had every symptom of approaching dis- 
solution, the exhibition of the enema was followed by such good 
effects that on the next day she might be pronounced out of danger. 
I have not used this injection myself, but I think the principle on 
which Dr. Graves employs it is just, and, as far as a trial of it has 
been made, there is reason to hope for favourable results. At all 
I events, we may look upon it as a valuable addition to our means of 
! combating this terrible symptom.* 

Now, with respect to the pneumonia of fever, I have, in the first 
place, to remark, that this affection, though less frequent than bron- 
chitis, is of equal importance. Suppose that, during the course of 
fever, your patient gets cough, hurried breathing, and perhaps some 
pain in the chest; he has dulness of sound extending over a con- 
siderable portion of the lung, and, on applying the stethoscope, you 
find crepitating rales and feebleness of respiration. In cases of this 
kind, the value and efficacy of treatment will mainly depend on the 
period of fever, the strength of the patient, and the nature of the 
preceding symptoms. The more the fever is of the inflammatory 
type, the earlier the period of the disease is, and the smaller the 
amount of prostration, the more favourable the prognosis. If the 
patient is of a robust constitution, the fever of short duration, and 
the prostration inconsiderable, you may venture on a single small 
bleeding, but this must be performed with caution, and always 
bearing in mind, that an attack of this kind requires very different 

* [An increase of the secretory functions of the kidneys will afford relief in the 
circumstances just described in the text. For this purpose, cold infusion of poly- 

j gala senega with spirits of nitre, or a quarter of a grain of calomel with some of 
the powdered root, and a few grains of nitre every two hours, will be serviceable. 
A minute proportion of opium may be added. Alternately with this, we should 
give a few drops of the balsam of copaibse, with equal proportion of spirits of 

I nitre and wine-whey. I have found that the balsam pretty uniformly diminishes 

I pulmonary secretion. — B.] 



48S 



STOKES'S THEORY AND PRACTICE. 



treatment from the ordinary idiopathic pneumonia. We next pro- 
ceed to the use of local bleeding, and of calomel and opium, if the 
stomach will bear it. It generally happens that the system will 
come under the influence of mercury in two or three days, but in 
some cases you will not be able to affect the mouth, and these you 
may look upon as the worst cases, and very likely to prove fatal. 
We often witness here a kind of struggle between the mercurial 
action and the disease. To-day the gums are slightly sore and 
the breath mercurial : to-morrow all this is gone, although the 
remedy has been steadily continued. Next day you will observe 
a slight return, and so on. In such a case as this, full ptyalism is 
almost never produced, and the disease is commonly the victor. 
I have only known two cases to recover out of a vast number 
in which we observed this circumstance. With respect to blisters, 
counter-irritation, diet, &c, the same rules apply here as to 
the catarrh of fever. Tartar emetic is altogether inadmissible in 
the treatment of this kind of pneumonia ; it can be used with safety 
in those cases only where free general bleeding may be employed, 
and this can never enter into the treatment of typhus, where gene- 
ral debility is ordinarily the most prominent symptom. Besides, 
there is in almost all these cases a complication with gastro-enteric 
disease, and where this exists, the use of antimonial medicines is 
always dangerous.*' On this account we give a preference to the 
calomel and opium, assisted by blisters, stimulant expectorants, 
and a light nutritious diet to support the patient's strength. When 
you find the skin pale and cool, the pulse weak and small, and the 
features shrunk, you should always give wine. This disease is 
generally very slow in resolving, the patient convalesces tediously, 
and requires to be constantly watched. 

W e now come to the most important part of the analysis of the 
symptoms of fever, namely, those which have been termed gastric. 
In using the term gastric, I wish it to be understood as referring 
not merely to the stomach, but also to the whole digestive tube, the 
liver, and spleen. Of all the symptoms of fever, the gastric are 
the most frequent, the most numerous, the most remarkable for 
their extent, persistence, and insidious latency, and the most fre- 
quently connected with actual organic change. Of this proposition 
I think there cannot be the slightest doubt. If we look to the 
different parts of the system, we shall find that, of all others, the 
digestive tube is most liable to disease, whether we consider the 
typhus of this country, or the malignant fevers of warm climates. 
To undertake the treatment of fever, without an accurate know- 
ledge of the physiology and pathology of the digestive system, and 
the intimate connection between it and fever, would be nothing 
better than practising in the dark ; and I feel perfectly convinced 

* [Experimental observations, by Bayle and others, do not authorize this asser- 
tion, which used to be so frequently and so earnestly made by Broussais. But as 
regards the practical fact ; I have not derived the same benefits from the use of 
the tartar emetic in fevers generally as I have in thoracic diseases and in rheu- 
matism. — B.] 



FEVER. 



489 



that it is to the want of this knowledge we are to attribute the 
ignorance, the empircism, and the want of success, which have so 
long disgraced the treatment of fever. If you were to do nothing 
for years but study the pathology of the digestive system in fever, 
your time would be well and profitably employed, and you would 
have occasion, almost every day of your professional life, to con- 
gratulate yourselves on the importance of the knowledge you have 
obtained. There is no system so intimately connected with fever 
as the digestive, and this leads us to a consideration of what has 
been termed the physiological theory of fever, which has created 
such a sensation in modern times. It may not be amiss, therefore, 
to make a few observations on the rise and fall of the physiological 
doctrines, before we proceed to discuss the gastric symptoms of 
typhus. 

The physiological theory, as propounded by Broussais, may be 
considered under two general heads : first, those doctrines which 
apply to disease in general, and, secondly, those which apply to 
fever and its varieties. M. Broussais appeared before the medical 
world at a time when it was exceedingly natural that a man of 
his great talents should erect himself into the founder of a new 
school. Humoral pathology, which had been gradually falling into 
disgrace, had already received a severe shock from the results of 
anatomical investigation ; and it was before the time of Broussais 
that the immortal Bichat had described the different tissues which 
enter into the composition of the body, and the division of nerves 
into those of animal and organic life. Pathological anatomy was 
advancing rapidly in its brilliant discoveries ; and, as every day 
added to the mass of important facts bearing on the nature and seat 
of disease, Broussais announced that many affections, looked upon 
as essential by the old pathologists, could be distinctly traced to a 
local cause ; in fact, that a numerous class of diseases were reduci- 
ble to the phenomena of local inflammation. These discoveries 
were hailed with acclamation by a host of admiring disciples, and 
were expected to lead to the most splendid and important results. 
The captivating simplicity of a doctrine which attributed all dis- 
eases to changes in the solids, thus deriving additional support 
from the investigations of anatomy, and coinciding with the feel- 
ings of the time, could not fail in attracting a host of admiring fol- 
lowers. Besides, most persons were disgusted with the glaring 
absurdities which were put forward as part of the doctrines of the 
humoral school. Their pathology consisted almost exclusively of 
crude notions of certain changes in the fluids, which they termed 
alkalinity or acidity of humours, corruption of bile, inspissation and 
1 tenuity of blood, putrefaction and fermentation of fluids. These, 
I with some strange ideas of the existence of peculiar unknown 
j fluids in certain parts, as the spirits of the brain, the choler of the 
liver, &c, were the floating and obscure notions which preceded 
I pathological anatomy. All the ingenious, the inquiring, and those 
who regarded not dogmas because they had been propounded by 



490 



STOKES'S THEORY AND PRACTICE. 



great names, became disgusted with the intangible obscurity and 
manifest absurdity of the doctrines of the humoral school ; and 
embracing every new discovery in science which appeared calcu- 
lated to shed a better and a steadier light on the nature of disease, 
they embarked with ardour in the pursuit of pathological anatomy. 
As anatomy and pathology advanced, the healthy and then the 
diseased condition of the solids became the topics for investigation, 
the attention of medical men was turned from the speculations of 
humoralism to the study of known and perceptible alterations in 
the solids; and hence it was that attention became exclusively 
directed to the solid parts of the body. 

A little before this time appeared the celebrated Dr. Brown, of 
Edinburgh, one of the most remarkable men of modern times, 
whether we consider his boldness, or his ingenuity in defending 
his doctrines. He declared that life was supported by stimulants, 
and that disease was referable to one or two states of the system of 
an opposite character — one of which he called sthenia, the other 
asthenia. Thus he divided all diseases into those of sthenia or 
excess, and of asthenia or deficiency of vitality. All diseases being 
thus reducible to one of two conditions, all treatment was reduced 
to the employment of general stimulation and general depletion ; 
for these terms applied not to the local disease, but to the state of 
the whole economy. Bichat, however, demonstrated the separation 
in function and structure which exists among the various organs 
of the body ; and M. Broussais, being fully aware of the untenable 
nature of some of the doctrines of the sthenic and asthenic theory, 
proceeded in forming his own doctrines, and applied the principles 
of Brown, not to the whole economy, but to each separate organ and 
tissue. He declared that one part or organ might be in a state of 
asthenia, or, as he termed it, have a minus degree of vitality, at the 
same time that another organ was in a state of sthenia, and enjoy- 
ing a plus degree of vitality. He thus modified very considerably 
the theory of Brown, applying to each separate organ and tissue 
those terms which Brown had applied to the system generally. 
Brown thought there could not be sthenia of one part and i 
asthena of the rest at the same time ; Broussais declared that all 
diseases were referable to a plus or minus degree of vitality, and 
that either of these conditions might exist in any particular tissue 
or organ ; and that one part might be in a state of sthenia, while 
another part, or even the rest of the economy, might be at the same 
time in a state of asthenia, and vice versa. 

Disease, then, according to Broussais, consisted in an exaltation 
or depression of the vital action of the affected part ; and, as symp- 
toms of disease were reducible to irregularity of function, and func- 
tion being the product of organs, and organs being the solids of the 
body, it followed that affections of the solids alone are the cause of 
all diseases, and therefore that the doctrine that fever is an essential 
disease or general affection of the system, not referable to disease of 
any of the solids, was wrong, and the cause of it was to be sought 



FEVER. 



491 



for in some changes occurring in the solids. Now, as inflammation 
of the digestive tube is one of the most constant lesions observed in 
fever he took it as the pathological character of fever, and therefore 
concluded that fever is only symptomatic of gastro-enteric inflam- 
mation, and not in itself an original affection of the whole system, 
of the nature of which no one knew anything. 

Such are the chief arguments of the physiological school. They 
| contend that ah the phenomena of fever are reducible to the symp- 
I toms of local disease of the digestive tube, and the sympathetic 
effects produced by it on various parts of the system. Many cir- 
! cumstances contributed to render this theory plausible, and recom- 
I mended it to the adoption of medical men. In the first place, there 
was the great similarity in symptoms, which is so frequently 
j observed to exist between the ordinary idiopathic gastro-enteritis 
and typhous fever. In the next place, the constant occurrence of 
! cases of idiopathic gastro-enteric inflammation in which the ac- 
companying fever, though purely symptomatic, bears a strong 
j analogy to typhus. This resemblance of the fever of gastro-ente- 
ritis to typhus was one great cause of the theory being so well 
I received. Another circumstance was the discovery of the fact, 
that of all systems the digestive is that which most intimately sym- 
pathizes with, and produces the most striking effects on, the brain 
and nerves. To give an example of this, if you compare the 
inflammatory affections of different systems and organs, with 
respect to their tendency to produce prostration of strength, you 
I will find that this tendency is produced by affections of the digestive 
system to a much greater degree than by those of any other. A 
patient may have extensive pleuritis, or pneumonia, or pericarditis, 
or even cerebritis, without any remarkable prostration ; but let him 
get but a slight attack of gastro-enteric inflammation, and the pros- 
tration of strength becomes almost immediately a striking symptom 
of his disorder. Now in typhus, also, this prostration of strength 
is one of the most remarkable phenomena, and, as it has been gene- 
rally observed that the prostration of strength in typhus is propor- 
tioned to the amount of gastric derangement, the disciples of the 
physiological school were thus furnished with an additional argu- 
ment. A third circumstance was the known tendency of gastro- 
enteric disease to produce symptoms of morbid action in the 
respiratory and nervous systems. We find an infinite variety of 
these symptoms in typhus, and we know that in other cases they 
can be traced to the sympathy which attends irritation of the 
digestive apparatus. One of the , most remarkable circumstances 
in typhus is the alteration of the fluids of the body. If you draw 
I blood from the system, you will often find it of a dark colour, with- 
I out any appearance of buff, that there is but little separation of 
| serum, and that the clot is soft, without consistence, and easily 
! broken up. There are also various morbid alterations in the per- 
| spiration, urine, and alvine discharges. Now, of all diseases, 
derangement of the digestive organs is the most likely to produce 



492 



STOKES'S THEORY AND PRACTICE. 



this alteration in the fluids. The digestive system is the main- 
spring of the economy, the great alembic in which the materials 
for repairing the waste of the system are elaborated, the fountain 
from which the blood is supplied for all the various purposes of 
secretion. Now, if the digestive system be in a state of disease, 
and incapable of performing its functions in a perfect manner, it 
cannot furnish the materials of good or wholesome blood ; and 
hence it is that the most remarkable ulcerations of the fluids of the 
body are observed in cases of gastro-enteric disease. A fourth cir- 
cumstance, in favour of the physiological theory, is the great fre- 
quency of symptomatic fever in warm climates ; and it is well 
known, that, in these countries, the digestive system is much more 
liable than any other to the impressions of disease. Fifthly, the 
results of pathological anatomy seemed to give support to the 
opinion, that fever is symptomatic of gastro-enteric inflammation, 
for, in a vast number of cases, we find not only irritation but even 
extensive inflammation and ulceration of the mucous membrane of 
the digestive tube. Lastly, the results of treatment tended to give 
these doctrines additional and, indeed, most important support. 
The founder of the physiological school claimed credit for his doc- 
trines, inasmuch as a practice, based on these doctrines, had been 
much more successful than that pursued by his predecessors. 
This admits of a twofold explanation. In the first place, as the 
theory of fever was founded on local inflammation, it followed of 
necessity that the treatment should be antiphlogistic. Now, it is a 
well known fact, that the antiphlogistic treatment of fever is, on the 
whole, more successful than the stimulant. Here was one circum- 
stance, the change of practice from the old stimulant plan to the 
antiphlogistic, and consequently a greater degree of success. In 
the next place, was the remarkable efficacy of local antiphlogistic 
means, a practice for the introduction and inculcation of which the 
medical world is deeply indebted to Broussais. No one, I think, 
will venture to deny the great utility of local bleeding in the treat- 
ment of fever. But, though we must confess that it is one of the 
best remedies we can employ in a vast number of cases, still we 
do not regard it in the same point of view as the followers of 
Broussais, nor do we conclude that a fever is symptomatic, because 
leeching has been followed by favourable results. Local bleeding 
is of use, because it relieves or modifies a disease which has sprung 
up in the course of the fever, and which reacts on the economy 
in proportion to its intensity, and the susceptibility of the patient ; 
and the cessation of other symptoms, which frequently ensues on 
the application of leeches to the belly, is to be explained on the 
principle, that by removing an irritation, which powerfully reacts 
on the system, and thereby impedes the efforts of nature, we 
reduce things to a state of simplicity, and favour the ordinary 
tendency of the disease to a critical termination. 

Such are the circumstances which have contributed to support 
and advance the theory of Broussais ; circumstances which, I 



! 



FEVER. 



493 



think, have not been sufficiently considered, or properly appreciated 
by those who have decried his doctrines and practice. On the 
other hand, it is true that this theory was formed too hastily, and 
defended too dogmatically. Happy would it be for mankind if it 
were true, for then we should have a key to the nature and treat- 
ment of the most extensive and fatal of all human affections. The 
great error of Broussais consisted in the hasty generalization of the 
i facts on which he based his doctrines ; these were neither suffi- 
I ciently connected, nor was their value sufficiently appreciated. 
| Since the publication of his opinions, many facts have been brought 
I forward ; and these of so strong a nature, as to induce men to take 
I a different view T of the subject, and to consider the gastro-enteric 
inflammation (so frequently observed in typhus) not as the cause 
I and essence of the disease, but merely as one of the various second- 
! ary lesions which arise during its progress; that fever may occur 
! without gastro-enteritis (which is the rarest cause), or w T ith very 
little of it ; that there is no constant relation between it and the 
; extent of the disease ; and, therefore, that a treatment, chiefly 
1 limited to the employment of local antiphlogistic means, is not 
I founded on a rational view of the subject. 



LECTURE XLIV. 

I Different lesions in typhous fever — Absence of gastro-enteric symptoms — Cases by Bouil- 
Iaud, Andral, Louis, &c. — Andral's arrangement of fevers — Louis's opinion on the 
anatomical character of fever — Analogy of typhus with small-pox — Absence of pain 
in enteritis — Means for diagnosis — Variety of disease in serous tissues from typhus 
— Treatment of the digestive symptoms of typhus — Hiccup — Tympanites in fever, 
treatment of — General treatment of fever — Conclusion of the course. 

To-day we have to consider the treatment of the gastric symptoms 
which occur during the course of typhus. 

At our last meeting, I endeavoured to impress on your attention, 
that of all the lesions of typhus those which belong to the digestive 
system are the most remarkable, on account of their extent, variety, 
frequency of occurrence, and number of sympathetic relations ; and 
that, consequently, this was, perhaps, the most important part of 
our analysis of the phenomena of typhus. I spoke of the theory of 
Broussais, and showed that many circumstances tended to render 
that theory at least exceedingly plausible ; but that the progress of 
medicine had tended to shake the stability of the physiological doc- 
trines, as far as typhus is concerned, and to prove that, however 
extensive and frequent lesions of the intestinal canal may be, still 
| they cannot by any means be looked upon as the first link in the 
I chain of morbid action, nor typhus be considered as merely symp- 
j tomatic of gastro-enteritis. If such were the fact, these lesions 
I should exhibit an uniform constancy of occurrence, and their 
I amount should be always proportioned to the severity of the symp- 
| toms. We cannot recognise either of these characters in typhus. 



494 



STOKES'S THEORY AND PRACTICE. 



The symptoms are very seldom in proportion to the gastro-enteric 
affections, and they are not of constant occurrence. Indeed, cases 
of typhus have been recorded by medical writers, in which, the 
phenomena of gastro-enteric inflammation were totally absent. 
You will find several cases of this description mentioned by Bouil- 
laud, Andral, and other practitioners of eminence; and even Louis, 
who says that the anatomical character of fever seems to consist in 
organic derangement of the mucous glands of the intestines, 
acknowledges That he has met with cases of typhus without any 
gastro-enteric lesion. We may then, I think, freely admit the con- 
clusions which Andral has drawn from a most extensive analysis 
of the pathological characters of fever, that lesions of the digestive 
tube are not of constant occurrence, and that fever may exist inde- 
pendent of gastro-enteric disease ; but on the other hand, that in 
the majority of cases we meet with traces of more or less extensive 
derangement of the intestinal canal. If this be true, and I think 
there can be little doubt of it, it is quite sufficient to prove how 
important, how indispensable, must be the study of the digestive 
system in typhus. If you refer to the best practical treatises on 
fever, published in this country, you will meet with innumerable 
instances of the remarkable prevalence of gastro-intestinal disease 
in typhus ; and in France so constantly have inflammation and 
ulceration of the mucous glands of the ileum, and other portions of 
the intestinal canal, been discovered, that Andral, in his last edition 
of the Clinique Medicale, ranges fevers under the head of abdo- 
minal diseases. It is very probable that, in France, these second- 
ary lesions are more frequently met with than in this country, and 
this I freely admit ; but I can say, that even here they are exceed- 
ingly common, and form a most important and prominent feature 
in the pathology of typhus. 

I need not tell you that the part most commonly affected is the 
mucous expansion of the digestive tube. The stomach and the 
lower third of the ileum, particularly the latter, are most liable to 
disease, and it is here we generally look for organic alterations of 
the bowels in fever. We find many cases of typhus without any 
disease of the stomach, or with lesions of a very trifling nature ; 
but this observation does not apply by any means in an equal 
degree to the small intestine. Again, the morbid appearances of 
the stomach in this disease have not in them anything special, or 
connected with the phenomena of typhus, and they exhibit very 
little difference in persons who have died of typhus and those who 
have not ; but in the small intestines there is, under the same cir- 
cumstances, a very remarkable frequency and uniformity of lesion. 
Louis has stated it as his opinion, that the anatomical character of 
fever is inflammation of the intestinal mucous glands. Where 
gastro-enteric symptoms are present, we generally find, on dissec- 
tion, that the mucous membrane, particularly of the lower third of 
the ileum, is in various states of disease. In some cases, the lesion 
is confined to the mucous membrane itself, which become softened 



TYPHOUS FEVER. 



495 



j and unusually vascular ; but, in the majority of instances, you will 
i find both the mucous membrane and glands affected. The solitary 
I and aggregate glands become enlarged, and appear to be increased 
! in number. This, however, is not the case. Under the influence 
j of the inflammatory process they become hypertrophied, and, being 
| thus rendered prominent and distinct, vast numbers of them are 
| easily seen, which, in the natural state, *would have escaped the eye 
I of the closest observer. This disease sometimes appears to affect 
; the glands primarily, and has been termed exantheme interne, from 
j its resemblance to small-pox. It commences with increased vas- 
| cularity and turgescence, followed by softening and ulceration. 

In the first accounts of this affection, it was supposed to be quite 
! analogous to small-pox, and that the one w T as an eruption on the 
\ mucous surface of the bowels, as the other was an eruption on the 
i skin. This opinion, however, has been disproved by the following 
I facts: — In variola, we all know that there is a constant relation 
between the state of the cutaneous affection and the period of fever. 
There is no such thing as this in inflammation of the intestinal 
I mucous glands. In some advanced cases of fever, we find the 
glands only in the first stage of inflammation ; while, in other 
cases, where fever has been of very brief duration, we find them in 
| the last or ulcerative stage of the disease. These facts tend to inva- 
| lidate the notion of there being an analogy between this affection 
and small-pox, and shows that what has been looked upon as a 
I pustular eruption affecting the surface of the intestinal tube, is 
! nothing but an inflammatory state of its mucous glands, which 
may occur at any stage of typhus, and bears no relation to the par- 
ticular period of fever. 

With respect to the extent of this disease of the intestinal glands, 
there is considerable variety. In some patients we find it very 
extensive, and forming a large sheet of ulceration ; in others it is 
confined to a few small isolated patches. We may meet with it 
under its different phases of turgescence, softening, or ulceration ; 
or we may have these three states coexisting in the same indi- 
vidual. 

It may be asked here, if this ulceration of the glands be a common 
occurrence in fever, how is it that persons will recover'? This is 
j answered by the researches of pathological economy, which have 
j shown that these ulcerations, even though numerous an exten- 
| sive, are capable of taking on the process of cicatrisation and cure. 
| This fact has been established by the discovery of numerous cica- 
j trisation in the situation of the glands of those persons who 
! recovered from fever and died of some other disease. Under these 
I circumstances we find the mucous membrane of the intestine pre- 
, senting numerous minute patches, covered by a fine membrane, 
i destitute of villous processes, and resembling those cicatrices on 
I the surface of the body, which point out the situation of portions 
| of the skin which have* been deprived of vitality. 

When speaking on the subject of enteritis, I drew your attention 



496 



STOKES'S THEORY AND PRACTICE. 



to a valuable observation in Dr. Cheyne's report, that, in many 
cases of fever, what has been termed doubtful and imperfect con- 
valescence, depends on inflammation of the intestinal mucous 
glands. This leads us to the knowledge of a curious and import- 
ant fact, namely, that a crisis may take place and fever subside, and 
yet the disease of the digestive tube may still go on, and even ter- 
minate in the destruction of life. Circumstances analogous to this 
have been also observed in other diseases, in which we find the 
local affection remaining after the subsidence of the fever, by which 
it was accompanied or preceded. 

In speaking of enteritis, I drew your attention also to the occa- 
sional absence of all pain in cases where dissection proved the 
existence of extensive inflammation. This occurrence is still 
more remarkable in typhus. It has been often remarked, that 
idiopathic inflammation of the mucous glands is generally a pain- 
less and more or less latent affection. Now, if this be the case 
with idiopathic disease, how much greater will be the chances of 
latency and absence of pain in the glandular derangement which 
occurs in typhus, where the general sensibility is impaired, and 
where every form of local inflammation is remarkable for the 
trifling amount of suffering it produces, and the insidious latency 
of its origin and progress. And hence it is that extensive disease 
may arise and proceed unchecked in its career to a fatal termina- 
tion, without ever attracting the notice of the physician, or eliciting 
a single expression of suffering, or even uneasiness, from the 
patient. But the absence of pain is no proof of the non-existence 
of this treacherous malady. I have said before, and I now repeat 
the expression, that inflammation of the intestinal glands may exist 
in its most deadly form without any manifestation of pain or dis- 
comfort on the part of the patient, which would indicate where the 
evil lurks, and teach us where we should apply the resources of our 
art for its palliation or removal. 

You will ask me, is there anything capable of furnishing us 
with means of detecting this insidious affection? There is. Some- 
times we find a degree of tenderness on making firm pressure over f 
the region of the ileum, but this is by no means of constant occur- ! 
rence. But the most important aids towards forming a correct 
diagnosis are furnished by three symptoms, most commonly found 
in connection with these latent pathological changes. The first of 
these is great thirst without vomiting, and, generally speaking, a pre- 
ference for warm drinks. The next is early tympanites. The last 
is the occurrence of diarrhoea. These are the symptoms generally 
observed in cases where disease predominates in the small intes- ! 
tines. Thirst, with a preference for warm drinks, is a very 
common symptom of this affection; and the occurrence of early 
tympanites is, generally speaking, an ordinary accompaniment, 
and tends to throw much light on the natuie of the disease. With 
respect to diarrhoea, it may be stated, as a general proposition, that, 
in the course of typhus, diarrhoea, when not critical, is one of the 



TYPHOUS FEVER. 



497 



most positive indications of an inflammatory condition of some por- 
tion of the digestive tube. In many cases, diarrhoea does not 
appear until ulceration of the mucous membrane has taken place. 
Previous to the occurrence of ulceration, we have an increase of 
fever, with thirst, and perhaps some tenderness of the belly, and 
then diarrhoea sets in. There is nothing more common in hospital 
practice than to see a case of apparently simple essential fever 
going on without any particular abdominal symptom for ten or 
fifteen days, when it begins to change its character, diarrhoea sets 
in, and runs the patient down rapidly, and, on dissection, we find 
j extensive ulceration of the small intestines.* 

I have told you that in cases of fever, where the digestive system 
! is engaged, we very seldom meet with disease of the peritoneum, 
or other serous tissues. Still it is possible, and examples of it are 
occasionally observed. In some instances, where this inflammation 
of the mucous membrane and glands of the small intestines (or, 
as it has been termed, dothinenteritis) existed, we have seen peri- 
tonitis coming on at an advanced period of the disease. Now, this 

I may occur by the direct transmission, or extension, of disease from 
the mucus of the serous surface, or it may arise from ulceration 
producing perforation of the three coats of the intestine, and effu- 
sion of its contents into the cavity of the peritoneum. A case of 
this description is almost invariably fatal. Neither is this perfora- 
tion of the intestine an accident of such rare occurrence as might 
be supposed. Indeed, when we consider the frequency of dothin- 

i enteritis, we are rather inclined to wonder that it is not more 
common. This, however, seems to be explained by recollecting, 
that these ulcers almost invariably open on the mucous surface of 
the intestine and spread laterally ; that they are generally super- 
ficial, and have very little tendency to pass deep into the wail of the 
intestinal canal. Still a patient in typhus, labouring under dothin- 
enteritis, is in a very bad and precarious condition. A man in 
fever, with prostration of strength, thirst, tympanites, and diarrhoea, 
is always in danger ; for he may in a moment be seized with alarm- 
ing peritonitis, and sink in a few hours. Under these circum- 
stances, you may be pretty sure that he has been carried off by 
peritoneal inflammation, and you may make the diagnosis of per- 

| foration of some part of the last twelve inches of the ileum. The 

j truth and accuracy of this diagnosis we have confirmed in the 

J Meath Hospital by numerous dissections. Its principle is founded 
on three circumstances : the preexistence of symptoms of disease 

i of the mucous glands ; the sudden supervention of symptoms of 
peritonitis, without anything to account for it; and the rapid sink- 

j ingof the powers of life. I have made this diagnosis with success 
in ten cases, which occurred at the Meath Hospital, and in others 

! in private practice. You will find a great deal of interesting 

* [See, for farther particulars on this subject, the notes added by the editor to the 
j lecture on Ileitis, p. 99-102 of this edition ; and also his lecture on typhous fever, 
i in the second part of this volume.— B.] 

43 



I 



498 



STOKES'S THEORY AND PRACTICE. 



matter on this subject in the Anatomico-Pathologieal Researches of 
Louis, who first made and established this diagnosis. I would 
also beg leave to refer you to my paper on Peritonitis, published in 
the London Cyclopaedia of Practical Medicine. 

We come now to the treatment of the digestive symptoms of 
typhus. We often find the patient complaining of thirst, with a 
desire in some cases for cold, in others for warm, drinks. As far 
as I have seen, the preference for cold drinks is most evident in 
cases where signs of irritation of the stomach exist, as tenderness 
of the epigastrium, nausea, and vomiting. One of the first observa- 
tions I shall make is, that, in all cases where there is great thirst, 
you should be cautious in the administration of stimulants. The 
circumstance of intense thirst always points out the existence of 
irritation in the stomach or intestines, or both, and this should 
make you very cautious (particularly in the early period of fever) 
in giving any stimulant, whether in the way of medicine, food, or 
drink. If the thirst be great, and accompanied by vomiting, the 
best thing you can do is to apply leeches, and this you will find 
productive of very great relief, particularly where there is epigastric 
tenderness. You may allow the patient also to drink cold water 
ad libitum. Many persons are afraid of doing this ; but it never 
does any harm, and is a great source of refreshment to the patient. 
We frequently give ice in cases of this description in the Meath 
Hospital. Against this practice, also, an outcry has been raised by 
some unthinking persons ; they say cold water, and more particu- 
larly ice, must be injurious, because we know that under cir- 
cumstance of fatigue, &c, their use has brought on a gastritis. 
This is a false argument. The circumstances are totally different, 
and the remedy in fever, with gastric irritation, has a wonderful 
value. If after the use of leeches, ice, and cold drinks, you find 
the disposition to vomit continuing, you will have recourse to the 
administration of opiates, and those best adapted for this purpose 
are the acetate or muriate of morphia, or the black drop. In cases 
of obstinate vomiting, the application of a blister to the epigastrium, 
and the sprinkling the raw surface with a small quantity of the 
acetate of morphia, will be found very useful. With respect to 
effervescing draughts, which are so commonly employed in cases 
of this description, I have already stated, when lecturing on gas- 
tritis, that their employment is very questionable, if not absolutely 
objectionable. They are very frequently rejected by the stomach, 
and the distension, which is produced by the evolution of gas, 
causes much distress and irritation. 

Another symptom, very often observed in connection with gas- 
tric derangement in fever, is hiccup, a symptom of which, in the 
great majority of cases, we know very little. In the early period 
of fever, I have found it coexist with inflammation of the cardiac 
orifice of the stomach; in the advanced stage, as far as my expe- 
rience of it goes, it seems to be more connected with general lesion 
of the nervous system. With these views, we may divide the 



I 



TYPHOUS FEVER. 



499 



I treatment of hiccup into two parts ; first, that which occurs in the 
| early stage of fever, and, in the next place, that which comes on 
j towards the close of the disease. In the former, we have found 
| leeching, cold drinks, and abstinence, the best remedies ; in the 
I latter, antispasmodic and stimulant remedies appear to be more 
I applicable. By reasoning, then, from experience, we find that 
! hiccup, in the beginning of fever, demands local antiphiogistics ; 
j but in the latter periods, when there is profound adynamia, it may 
! be treated with opiates, antispasmodics, and even stimulants. 
| A very common symptom in fever is tympanites. Here again, I 
! beg to refer you to my lecture on enteritis, as all I have said there 
I on this point is equally applicable to the present case. Tympanites 
j sometimes occurs at an early, sometimes at an advanced, period of 
; the disease. It is a symptom which is very often badly treated. 
| Many practitioners, the moment they recognise its existence, and 
! without ever inquiring into its cause, prescribe at once their 
favourite nostrum, turpentine, and bad consequences are too often 
: the result. What generally takes place is this, that after the exhi- 
1 bition of turpentine the tympanites disappears, but its removal is 
j purchased at too dear a price. All the symptoms of fever, thirst, 
heat of skin, excitement of the vascular and nervous systems, are 
increased, and, what is still more annoying, the tympanites returns, 
and is as bad as ever. The rule by which you should guide your 
practice in the treatment of tympanites is this : if it occurs at an 
early period, when the skin is hot, the pulse quick, and the strength 
! undiminished, it is a sign of irritation or inflammation of the 
mucous membrane, and is to be met by appropriate treatment. 
Never employ stimulants for the removal of tympanites occurring 
at an early period of fever. But in the advanced stage, where the 
general inflammatory symptoms have subsided, where the skin is 
cool, the pulse weak, and the strength reduced, then you may 
exhibit turpentine with decided advantage ; but as long as the con- 
dition of the patient requires and admits of local antiphlogistic 
treatment, never have recourse to it. 

Diarrhoea is another very common symptom in fever. I have 
told you before that diarrhoea, when not critical, may be looked 
upon as an unequivocal indication of disease of the mucous glands 
of the intestines. With respect to the period of its occurrence, we 
may have it either in the early or in the advanced stage of fever, 
j When it makes its appearance at an early period of the disease, it 
i should not be too hastily interfered with ; for great danger has been 
! found to result from stopping it at this time by the exhibition of 
' astringent medicines. Bear this in mind. It is a common practice 
I with some persons to prescribe astringents the moment diarrhoea 
I appears. Now, this is founded on false notions of pathology. In 
j cases of inflammatory disease, one of the principal modes which 
i nature adopts in giving relief is, by super-secretion from the af- 
j fected organ. Now, if under such circumstances, you arrest a 
j diarrhoea of this kind occurring at an early period, you do it at the 



500 



STOKES'S THEORY AND PRACTICE. 



i 



risk of producing intense enteritis or effusion into the peritoneum. 
When it comes on at an early period, all you should do is to apply 
a few leeches to the belly, and give small doses of hydrarg. c. creta 
with Dover's powders. You may also use mild anodyne injec- 
tions ; but in the treatment of this affection, always seek to arrest, 
not the disease but its cause. This is the true mode of proceeding. 

In the advanced period of fever, where the pulse is small and 
low, and the strength sinking, diarrhoea is a very alarming symp- 
tom ; for, if not speedily arrested, it will run the patient down in a 
very short time. Here, and here only, is the use of astringents 
demanded, and it is here that their beneficial effects are manifest. 
To arrest this dangerous symptom which is precipitating the case 
to a fatal termination, you must use opiates combined with astrin- 
gents, and you may give wine if necessary. 

From a consideration of the physiological characters of the 
digestive system — from the study of its pathological condition in 
fever — from a review of its form, structure, and functions, in 
health — and from the fact of its extraordinary liability to inflam- 
mation in fever. I think you will be prepared to admit, that the 
common practice of purging day after day, in typhus, must be pro- 
ductive of the worst consequences. I beg you will impress this 
firmly on your minds, for so universal has this practice been, that 
you will find it difficult not to be carried away by the tide of preju- 
dice, when you come to be engaged in the duties of your profession. 
A common practice has prevailed in these countries, and, indeed, 
still exists to a very great extent, of making the patient take purga- 
tive medicine every day ; and this, I regret to say, is too often done 
even in cases where the surface of the small intestine presents 
extensive patches of ulceration. Now, I will ask you can any 
thing be so barbarous as this, or can it be exceeded in folly and 
mischief by the grossest acts of quackery? Here we have an organ 
in a state of high irritation, and exhibiting a remarkable excite- 
ment of its circulation; and yet we proceed to apply stimulants to 
that organ, and to increase the existing irritation. Would it not 
be absurd in a case of inflammation of the knee or elbow joint to 
direct the patient to use constant exercise and motion'? Would it 
not be very strange practice to apply irritants to a raw and exco- 
riated surface? Yet something equally absurd, and equally mis- 
chievous, is done by those who employ violent purgatives in a case 
of inflammation of the digestive tube in fever. This has been the 
great blot in the history of British practice. Calomel and black 
bottle, and even jalap, and aloes, and scammony, have been pre- 
scribed for patients labouring under severe and extensive dothin- 
enteritis. Morbid stools are discharged ; and the more morbid 
they are, the more calomel and purgatives does the physician give 
to change their character, and bring them back to the standard of 
health. I want words to express the horrible consequences. Too 
often have I seen fever patients brought into the hospital with 
diarrhoea, hypercatharsis, and inflammation of the mucous mem- 



TYPHOUS FEVER. 



501 



brane, from the use of purgatives, administered before their admis- 
sion. Practitioners will not open their eyes. They give purgatives 
day after day — a very easy practice, and one for which there are 
plenty of precedents — but it is fraught with the most dangerous 
I consequences. I will freely admit that the disciple of the school 
of Broussais have gone too far in decrying the use of laxatives 
! altogether. But if they have lost hundreds by this error, British 
j practitioners have killed thousands by an opposite plan of treat- 
\ ment. In cases of fever, where there is no decided symptoms of 
I gastro-enteric disease, there can be no objection to the use of laxa- 
! tives if required, but they should always be of the mildest descrip- 
I tion. You will gain nothing by violent purging in fever. Mild 
laxatives alone can be employed ; and where there is any sign of 
intestinal irritation present, even these should be used with caution. 
There is one mode of opening the bowels which you may always 
have recourse to with advantage in fever, viz., the use of enemata. 
There is not the slightest doubt that occasionally accumulations 
of faecal matter will take place, and tend to keep up irritation, but 
they should always be removed with the least risk of producing 
bad consequences. To purge in fever when intestinal irritation 
is present, is a practice opposed alike to theory and experience, and 
I have already stated that its results are most horrible. 

It generally happens that in cases of severe fever, even where 
symptoms of gastro-enteric disease are still present, that a period 
will arrive when the patient's strength must be supported by nutri- 
! tious diet, wine, and other direct stimulants. Here the school of 
Broussais fell into a great practical error ; their notion being that 
the fever w T as symptomatic of the gastro-enteritis, and not the 
gastro-enteritis of the fever, they followed a rigorous antiphlogistic 
plan of treatment throughout the entire disease, and thus many of 
their patients died, not of gastro-enteritis, but of the debility and 
exhaustion brought on by protracted starvation. You should bear 
this in mind, and recollect that, even in health, a man cannot exist 
beyond a certain period without some kind of solid and nutritious 
aliment. In Dr. Paris's work on Medical Jurisprudence, you will 
find an account of a nobleman, who starved himself to death, 
which took place about the twenty-first day. But how many 
fevers exceed this period ? and can it be supposed that patients will 
survive or be able to wrestle successfully with disease unless their 
strength be supported by a certain quantity of nutritious aliment. 
It is decidedly a bad and erroneous practice to confine patients for 
weeks to the dilte absolue ; to give them, in fact, scarcely any 
1 thing but gum-water throughout the course of a long and exhaust- 
i ing disease. After the second week, you must look to the strength 
, of your patient, and if you find this sinking, endeavour to support 
; it by a mild nutritious diet ; and if this will not be sufficient, you 
I must have recourse to wine and stimulants. You may give nutri- 
ment and wine with advantage, even where you are still employ- 

43* 



502 



STOKES'S THEORY AND PRACTICE. 



ing local antiphlogistic means, supporting the system generally, 
while you are using measures to effect the removal of local disease. 

It would be impossible to lay down any rules with respect to the 
use of wine. Sometimes it will be required at an early, more gene- 
rally at an advanced period of the disease. You may, however, 
adopt this rule as applicable to the greater number of fever cases, 
that as long as the patient's strength and condition are such as to 
demand the use of antiphlogistic measures, you need not give wine. 
But when antiphlogistics are either no longer necessary, or when 
the patient's strength will hardly admit of them, when the pulse 
falls, and the skin loses its morbid heat, then you may give wine, 
and in such cases it very often produces the most remarkably 
favourable effects. It matters not how quick the pulse may be at 
this period, for one of the first effects of wine is to diminish its fre- 
quency, if it agrees with the patient. Here we arrive at a very 
important fact — that recovery almost invariably takes place where 
the pulse falls after the use of wine ; and this diminution in the 
frequency of the pulse not only affords good grounds for making a 
favourable prognosis, but also shows that we may persevere in the 
employment of wine with decided advantage. 

I feel certain that in these lectures many things have been 
imperfectly handled, and I know that many have been omitted 
altogether ; but I knew this would be the case from the commence- 
ment, and that it could not be remedied. I thought, too, that it 
was much better to study a few subjects well than many super- 
ficially. I was convinced that the present mode of compressing 
into a limited course of lectures observations on all diseases, is a 
useless attempt, impracticable in its nature, and having a most 
injurious effect on medicine. This mode of teaching generates 
bad habits on the part of the teacher and the pupil; it makes the 
one satisfied with imparting, and the other satisfied with receiving, 
imperfect and limited information. It is better, I repeat, to know a 
few things intimately than many things superficially. If you 
examine the history of those men who have acquired the most 
brilliant reputations in the world of science, you will find that it 
was not so much by the universality of their information, as by 
their profound knowledge of a few important subjects. 

In the present course of lectures, I have selected for my subject 
three great classes of disease, namely, those of the digestive, the 
respiratory,* and the nervous systems, and, having done this, I have 
proceeded to the consideration of fever. On these important affec- 
tions, I have endeavoured to communicate as much knowledge as 
my brief and limited space would allow. I have not touched on 
hydrophobia, tetanus, hysteria, and some other nervous diseases of 
less interest ; neither did my time permit me to direct your atten- 

* [The diseases of the respiratory system are not included by Dr. Stokes in 
this course of lectures. This subject has been treated by him in another work with 
his characteristic ability. In the subsequent lectures which I have added to 
this edition, the reader will see how largely I have borrowed from its pages. — B.] 



TYPHOUS FEVER. 



503 



tion to the derangements of the circulating system, or cutaneous 
complaints. Still I do not regret this, for I feel satisfied that I have 
done you more justice by pursuing this plan, than if I had taken a 
hurried and unsatisfactory sketch of the long list of human 
maladies. 

It has been one of my principal objects in these lectures to avoid, 
as much as possible, taking up your time with literary disquisitions. 
I was anxious that every observation of mine should bear on some 
point of practical importance ; 1 wished to communicate, as far as 
my information went, the true principles of treatment, and I shall 
deem my exertions more than repaid, if 1 have succeeded in im- 
pressing any one useful practical precept. The length of time 
necessary for giving a full course on the theory and practice of 
medicine should be much greater than it is at present. If spared 
by Providence to give another course of lectures, it would be my 
earnest desire to adopt, if possible, a different mode of lecturing ; to 
commence the subject of theoretical and practical medicine, and 
continue it through two, or, perhaps, three sessions, and to give 
minute and comprehensive lectures on all or the great majority of 
subjects which the ordinary courses on medicine certainly cannot 
comprise. It is only in this way that the whole of our knowledge 
on the present state of medical science can be made available. 



LECTURES 

ON THE 

THEORY AND PRACTICE OF PHYSIC, 

ADDITIONAL TO THOSE DELIVERED BY DR. STOKES, 

BY JOHN BELL, M.D. 



LECTURES 

ON 

THE THEORY AND PRACTICE OF PHYSIC. 



LECTURE I. 

Typhous fever not essentially different from typhoid fever — The general symptoms and 
organic changes nearly the same in the two diseases — Symptoms illustrative of func- 
tional lesions in the first stage of typhus — Indications thence resulting for selection of 
remedial means — Resemblance between typhus and poisoning — Cold baths — Emetics 
— Enema — Purgatives — Venesection — Modification of treatment by the constitution, 
prior habits and exposure of the patient — To increase the action of the depurating 
organs — Changes of treatment with difference of stage of the fever — Employment of 
stimulants in typhous fever — Indication for their use furnished by the state of the heart 
— Dr. Stokes's cases and observations — Caution in the general inference from hospital 
practice — Tartar emetic practice in typhus — Rasori's views and cases — Dr. Graves's 
opinion and cases — Utility of tartar emetic by the mouth and in enema, and in the 
form of ointment — Thirst, relief of — Not to forget the recuperative power of nature 
as shown by cures without medicine. 

Dr. Stokes, in his remarks on the anatomical characters of fever, 
and the analogy of typhus with small-pox, does not attempt to sepa- 
rate, under two heads, typhous and typhoid fevers, as has been done 
by some zealous pathologists of late years. These latter tell us that 
typhous fever is an exanthematous disease, is contagious, and does 
not leave behind it any uniform anatomical lesion or altered struc- 
ture of organs: typhoid fever, on the other hand, is not contagious, 
does not uniformly or characteristically exhibit an eruption, but 
has, as a constant character, an anatomical lesion, which consists in 
an alteration, by inflammation and ulceration of the glands of Peyer 
and Brunner, and inflamed mesenteric glands. The initial symp. 
toms of the two diseases differ in the earlier and greater stupor and 
suffusion of the eyes in typhus. Some of the French pathologists 
have proposed to designate typhoid fever by its anatomical charac- 
ter, and it is by some called dothinenteritis, or follicular enteritis. 
But a little inquiry will make us backward in assenting to the 
accuracy of this division, and of the distinctions on which it rests. 
Thus, it is known that typhoid fever has commonly an eruption, 



508 



TYPHOUS FEVER. 



which is stated expressly by M. Chomel to be one of its peculiari- 
ties, and to appear between the seventh and ninth days of the dis- 
ease ; — and it is accordingly mentioned in my long note on this sub- 
ject, page 101. Petechias and sudamina are clearly understood by 
M. Andral to be diagnostic symptoms. It is true that the pete- 
chia of typhoid are chiefly confined to the abdomen and anterior 
parts of the chest, and they are of a rose colour : those of typhus are 
for the most part general, and are of a slightly livid or purple tint. 

But, as regards the anatomical character of typhoid fever, we 
learn from the same excellent and impartial authority, M. An- 
dral, that patients have perished under this fever with all its symptoms 
well marked; yet still there was neither exanthema, certainly 
no ulcerations nor appreciable alteration in any part of the digestive 
tube. Can the proposition be inverted, and shall we be told that as 
there is typhoid fever without dothinenteritis, so there may be 
dothinenteritis without typhoid fever 1 This is the fact, since folli- 
cular enteritis has been found in other diseases, such as phthisis, 
scarlatina, remittent fevers, diarrhoea, and cholera. It were superflu- 
ous after this, to say that this variety of enteritis may go through its 
stages without giving rise to the phenomena of the fever called 
typhoid. Indeed M. Louis himself, the strongest advocate for the ana- 
tomical lesion of the intestines as constituting the fixed character of 
the fever, tells us that headache, which occurs in forty-nine out of fifty 
cases of fever, is not met with in two out of the same number of 
enteritis. The rose-lenticular spots, the sudamina, epistaxis, tym- 
panites, so common in typhoid fever, are rare in enteritis. This last 
disease may occur in infancy, may be repeated several times, and 
may complicate other diseases ; whereas typhoid fever rarely at- 
tacks very young or very old individuals. 

A few words more on the specific characters of typhus before a 
fresh comparison between it and typhoid fever is instituted. A 
belief that, typhous fever is contagious and is accompanied by a 
petechial eruption has been entertained and expressed by most of 
the writers on the subject, since the beginning of the sixteenth cen- 
tury. The disease has often been designated by the term petechial 
fever and petechial typhus, although this latter would imply that 
there are other forms of the fever in which petechias are not seen. 
This latter was the case in the jail fever of Winchester, described 
by Dr. C. Smith, to whom reference is made by Wilson (now 
Philip) in his work on Fevers. The petechial character is more 
constantly seen in typhous fever when it prevails over a great 
extent of country, or, as it is termed, epidemically. A memorable 
example of this form of disease occurred in Italy in the year 
1817, a history of which I transmitted in the latter part of that 
year to Dr. Wistar, and which was published subsequently in the 
first volume of Dr. Chapman's Medical and Physical Journal. In 
this paper I stated that some, among whom is Palloni (a distin- 
guished physician of Leghorn) with Hildebrand and others, considered 
the petechial typhus to be a distinct eruptive disease, arising from a 



RESEMBLANCE OF TYPHOUS TO TYPHOID FEVER. 50!) 



contagion sui generis, like small-pox or measles. Opposed to this 
opinion are Professors Franceschi of Lucca, and Valentini of 
Rome, who view the eruption as by no means an essential feature 
of the disease; in proof of which it has been remarked, that the 
| eruption is sometimes absent, sometimes papular, &c. Franceschi 
observed the eruptions only on the inside of the arms and thighs, 
j on the breast and lateral parts of the neck, but never on the face, 
j He says, that petechias do not terminate as other exanthematous 
\ or acute diseases of the skin, for no desquamation succeeds their 
j appearance, nor do any traces of their presence remain. The 
j eruption is neither critical nor symptomatic ; as is shown by the 
uniform shape of the spots, and by their affording no relief, and 
causing no detriment when they appear. 

There are, it is admitted, no fixed anatomical lesions in typhous 
fever; although some one organ or another commonly suffers 
I much during the disease, and manifests structural changes after 
death. I have, already, in a note to a former Lecture, adverted to 
, the resemblance between the symptoms of ramollissement of the 
brain and those of typhous fever ; and 1 find it stated in a report 
! of cases by Mr. Curling occurring in the clinique of M. Louis, that 
the latter twice mistook this fever for the former disease. Dr. 
Armstrong states, in his Lectures, that he has invariably found the 
brain and its membranes affected in more than one hundred cases 
without a single exception. 

If we were to institute a comparison between the two fevers, 
I typhous and typhoid, we should find many more points of resem- 
blance than of contrast. Both diseases have commonly an erup- 
tion, and both may prevail without any ; both are attended by 
frequent anatomical lesions ; the typhoid more constantly and gener- 
ally with one kind ; but both may run their course without any such 
organic change. In both fevers the digestive and the nervous sys- 
tems are the most deranged ; and in both there occur complica- 
tions of bronchial and pulmonary disease, and a morbid state of the 
heart. Typhus shows more frequently the brain, and typhoid 
fevers the intestines, to be the suffering organ. Softening of the 
left ventricle is one of the lesions noticed by M. Louis in persons 
dead of typhoid fever ; and we shall soon see what stress is laid by 
Dr. Stokes on feebleness of this organ in typhus, and how much he 
is guided by the symptoms which it furnishes, in his recommenda- 
tion of the use of wine by patients labouring under this fever. 
There still remains one point of broad contrast between the two ; 
and that is in the reputed contagiousness of typhus and the absence 
\ generally of this property in typhoid fever. But here, again, there 
j is a nearer approximation than might at first appear. Writers are 
, not entirely agreed respecting the non-contagiousness of typhoid 
i fever; and the warmest advocates of the contagiousness of typhus 
i admit its occasionally spontaneous origin. Dr. Stokes, both by the 
tenor of his preceding remarks and by his observations in a note to 
his paper on the use of wine in typhus, soon to be more fully 

44 



510 



TYPHOUS FEVER. 



noticed, obviously regards as lesions in typhous fever the ulcera- 
tions of the intestines, which have been assumed by some of the 
French pathologists to be characteristic of typhoid fever. 

I come now to a consideration of some points of practice in 
typhus, which, if the conclusions that I have drawn in the preceding 
remarks be correct, are applicable, also, to typhoid fever. A reference 
to the leading symptoms will enable us to appreciate better the 
functions most deranged, and thus give a proper direction to our 
therapeutical ministrations. In all the varieties of typhous fever 
the organs whose functions are primarily, evidently, and continu- 
ously enfeebled through the course of the disease, are the brain 
and the senses. The latter are dull, and the mind is heavy and 
stupid. Next to these, the most constant and even characteristic 
symptoms are increased frequency of pulse and augmentation of 
heat of the skin and body generally. With this capillary excite- 
ment and as effects of it, are injection and turbidness of the con- 
junctiva, and dingy suffusion of the face, extreme dryness as 
well as heat of the skin and petechial eruption ; the mucous mem- 
brane, exposed, to the air, as that lining the cheeks and gums 
and fauces, and continued into the larynx, trachea and lungs, is 
also dry and coated with dark mucus. Correspondingly if not 
similarly affected is the digestive mucous membrane, or that lining 
the stomach and bowels and continued into the glandular structure 
subsidiary to digestion. The excretory or depurating organs do 
not discharge their fluids of the customary quantity or quality : 
the urine is of a deeper colour, acrid, and offensive; the skin 
exhales, instead of its healthy vapour, a strong and offensive odour ; 
and the lungs, impeded in their functions, no longer throw offtheir pe- 
culiar secretions. We see then, evidently, that in typhus the capillary 
system is in a state of morbid turgescence so soon as reaction suc- 
ceeds to the first depression at the beginning of the disease ; but 
we see, also, that, notwithstanding the apparent preparation for 
secretion, this process is either arrested or greatly impaired, or 
where not impaired is greatly perverted. Such a condition of 
things can only happen in consequence of deranged innervation or of 
an altered and deteriorated state of the blood. The former may take 
place suddenly, and as suddenly affect the circulatory and secretory 
organs ; the latter requires somewhat more time for its completion, 
unless in cases of poisoning. The discoloration of the face and 
the dark hue of the lips indicate interrupted pulmonary circulation, 
which of itself could prove a cause of deteriorating the blood by a 
retention of carbon and of the common excretions from the mucous 
membrane. 

In classifying these several parts of the picture, we see that the 
skin and mucous membranes universally are in a state of irritation 
and perverted function; that the glands are equally deranged and 
congested by not being able to part with their customary propor- 
tion of blood for the purposes of secretion. All the nervous 
expansions, whether of the senses or on the skin and internal sur- 



INDICATIONS OF CURE. 



511 



faces, are morbidly affected and their functions disturbed ; as are 
those of the brain and spinal marrow, manifested by the feebleness 
of intellect and slowness and imperfection of thought and senti- 
ment in regard to the brain, and by morbid sensibility, pains and 
sometimes cramps in the voluntary muscles, as regards the spinal 
marrow. 

The indications for the employment of curative agents in this 
j simpler form of typhus are furnished by the state of the suffering 
organs. The heart is unduly accelerated, and hence the frequent 
i pulse ; the skin which is hot and acrid, and the mucous mem- 
! branes require to be restored to their appropriate secretory and 
I absorbing functions, and the glands to their secretory and depura- 
tory office. On the skin we should act at once by means of cool 
air, or, if this be wanting, cool or cold water supplied in the fashion 
| of sponging, or by affusion or immersion. Cool and cold bath- 
ing has been attended with excellent effects by often arresting 
the fever in its first stage, or by greatly mitigating the violence 
and gravity of the symptoms in its progress. In the somewhat 
analogous state of the system induced by a poison, such as opium, in 
which the capillaries are in a state of morbid excitement, and largely 
evolve animal heat, at the same time that the breathing is laboured and 
the brain oppressed, a shower-bath rouses the nervous system from 
its torpor, and restores the respiration to its former state. If we 
admit that this system is poisoned in typhus, we have an argument 
from analogy in addition to the positive experience of Currie, Jack- 
son, Giannini, and others, in favour of the cold bath, and particularly 
in the form of a shower, for the cure of this fever. According to the 
predominance of excitement in an organ or region, as, at one time, of 
the head, at another, of the epigastric region, will be the special direc- 
tion of the cold shower, or the application of cold cloths, or even 
of ice. Dr. Stokes has spoken of cold applications to the head ; I 
have used with marked benefit this remedy to the epigastric region, 
the heat of which, and indeed over the whole abdomen, is often 
so excessive in typhous and typhoid fevers. The patient will 
press with evidence of pleasurable sensation the cold cloths or ice 
folded in cloths on his epigastrium, and ask for a renewal of them. 
I speak under the supposition that our patient is labouring under a 
completely formed fever, and is in that stage in which professional 
assistance is commonly wanted. In the forming or preliminary 
stage, that in which the nervous system is the part chiefly affected 
and in which the temperature of the surface is unequal, the patient 
at one hour shivering, at another complaining of too much heat, a 
warm bath will prove to be soothing and salutary, and may, if its 
I operation be aided by simple drinks, bring on a diaphoresis, which 
i will restore the skin to its natural state and contribute to an equal- 
| izing of the other deranged functions. It is important to bear in 
mind the fact, that the salutary change which is brought about in 
the capillary circulation and secretions of the skin are responded 
to in a similar sense by the gastro-enteric and pulmonary mucous 



512 



TYPHOUS FEVER. 



membrane : the thirst, dryness and heat of the mouth and fauces, 
and the gastric sensations of heat, are all greatly mitigated after a 
cold bath or cold affusion. The breathing also is freer, and the 
expired air less hot and offensive after this remedy. 

Nausea and some efforts to vomit, are common symptoms in the 
inception of typhus. They who regard them as effects of diminished 
innervation, and analogous to those which occasionally occur in 
health from suddenly weakened action of the brain, will look for 
relief in a restoration of cerebral excitement. Some again, who 
see in the symptoms evidence of gastric disorder, or foul stomach, 
as the phrase is, prescribe an emetic with a view of cleansing out 
this organ, and at the same time clearing the bronchia of obstruct- 
ing mucus, and restoring the skin to a natural state by inducing a 
general moisture, which is sometimes converted into sweat. It 
seems to me that this point is susceptible of being examined in 
another light. It is well known to us all that the operation of a 
poison which is not directly and speedily narcotic, is to excite the 
stomach and bowels to empty their contents, and to pour out their 
mucous secretions, and soon after to excite all the organs of depu- 
ration or excretion, in order, as we should say, that the poison 
might be eliminated from the system. In all cases we are anxious 
to discharge the poison from the stomach, and if we can do so 
speedily, we prevent the train of symptoms which would otherwise 
follow ; and among these are narcotism — stupefaction, and oblitera- 
tion of sentiment, as well as violent efforts of the secretory organs. 
In typhus we are not prepared to say that there is a poison in the 
stomach, although it is very probable that this organ has been 
poisonously affected. At any rate, by an emetic we invert the pro- 
cess which was going on — we produce secretion and excretion, 
discharge from the stomach and bowels in place of the ab- 
sorption and introduction of depraved matters into the general 
system. If the pathological view just taken be a sound one, we 
must continue, by the use of purgatives, the elimination of matters 
from the digestive canal, which was begun by vomiting. The sub- 
jects of typhous fever, during the seasons of the greatest prevalence, 
are precisely of the class whose food anteriorly has been of an im- 
perfectly nutritive kind, such as to render it very probable that it 
has been imperfectly changed in the digestive canal, and that por- 
tions of it retained in the large intestine may serve as a real fomites 
of fever, a poison continually applied to a sentient and absorbing 
mucous surface. One of the first steps, therefore, as a matter of 
prudence, should be, after the operation of an emetic, to empty at 
once the large bowels by a strong enema, and then to administer a 
mercurial purge, consisting of calomel and rhubarb, — to be repeated, 
or to be followed by a compound powder of jalap, as circum- 
stances indicate. 

By this treatment we remove some of the probable causes, and 
abate, if not remove, some of the obviously troublesome symptoms 
in the first formed stage of typhus. In milder cases, this is often 



BLOOD-LETTING. 



513 



alone sufficient to check the farther progress of the disease, and to 
bring on convalescence. Whether we suppose that there was a 
morbid excitement which required subduing, or a poison which 
ought to be eliminated, we are justified in acting on the stomach 
and bowels in the manner already mentioned. If we do not thereby 
cure, we at least diminish the probabilities of farther mischief. By 
the cold affusion or continued application of cold locally, we abate 
the excessive heat, itself a disturbing cause both to the nervous and 
the capillary system, and we rouse the patient from the narcotism 
into which he had been thrown by the workings of the poison on 
the brain and senses. 

It may be thought that at the very outset of the disease we ought 
to satisfy ourselves respecting the question of blood-letting in 
typhus ; since if it is to be used, it may be alleged that the earlier the 
better. As a general rule, this is correct; but it is probably less 
applicable in typhous fevers than in most febrile and inflammatory 
affections. Still, recurring to the phenomena of admitted poisoning, 
and the treatment adopted in consequence, we find that early blood- 
letting is properly objected to until we can withdraw as much as pos- 
sible of the poison from the cavities and the surfaces to which it is 
applied ; for otherwise introduction of the poison into the vascular 
system, and its action on the nervous, would be increased by vene- 
section, since we know that absorption is singularly facilitated by 
this means. Again, — as Dr. Stokes has satisfactorily shown, various 
phlegmasia? may arise in the progress of the fever, which will 
require the use of the lancet, or the local detraction of blood ; 
although at the beginning these means are not called for, and are 
often contra-indicated. I shall not present the various authorities 
within the last twenty years in favour of blood-letting in typhus ; 
but content myself with remarking, that if when the reaction is 
completed, and there are distinct evidences in a somewhat full and 
slightly resisting or jerking pulse, great pain of the head and back, 
and congestion in the lungs or abdomen, we may open a vein with 
advantage, remembering at the same time to stop the flow of blood 
sooner than we would in the undoubted phlegmasia? or in other 
forms of fever more unequivocally marked by great excitement. 
The appearance of a bufTy coat will not encourage us to repeat the 
operation if the evidences already mentioned are not clear and forci- 
ble — nor will the absence of any buff cause regret if these enforce- 
ments are present. 

Much will depend on the prior state of the patient, his tempera- 
ment, particular exposure, and habits, as to the propriety of using 
' the lancet. One person may have been exposed to the operation 
! of causes which were fast bringing on cerebral inflammation or 
I meningitis ; and his case will require a large detraction of blood 
I similar to that practiced by Armstrong in this fever. Another had 
i chronic gastritis before typhus, and he will be benefitted at once by 
leeching, — a third again poorly fed and clothed, struggling against 
want, working hard, early and late, anxious for the morrow, not on 

44* 



514 



TYPHOUS FEVER. 



his own account but on that of a wife and children, will have been 
exhausted before the onset of the fever — his heart, already weak- 
ened with the perpetual mental anxiety, will sooner become softened 
and unfitted to propel the blood. This person cannot tolerate 
blood-letting, and but little purging: the stage of prostration is soon 
reached with him, and the urgency for administering wine and other 
stimulants is manifest. 

After having either practised venesection or used cups or leeches, 
or satisfied ourselves of the inappropriateness of these remedies, 
we may now resume the treatment already recommended to quicken 
the action of the depurating organs. With this view, we shall ad- 
minister calomel in small doses to aid the bowels and liver; tur- 
pentine and nitre, and other salts, including the hydriodate of 
potass, the kidneys ; polygala senega and squills, the lungs. For 
these latter, their appropriate hygienic exciter, pure and fresh air, 
should be freely admitted into the sick room or hospital w T ard, night 
and day. It will contribute powerfully to purify them from the 
morbid bronchial exudation, and to quicken the capillary circulation 
with its accompanying processes of oxygenation and decarbonation 
of the blood. The air ought to be diffused equally and gradually, 
not blowing in currents and with impulse on the body of the 
patient. If sometimes bronchitis predominate, calomel in small doses, 
say a grain every two hours, with polygala senega, will not be 
omitted. 

Throughout the whole course of a case of typhous fever, as in- 
deed of most fevers, and many of the phlegmasia?, we ought carefully 
to guard against the common error of bespeaking as it were, and 
persisting in a uniform plan of treatment and a certain series of 
remedies. Our not having bled at the beginning of the disease, is no 
good reason for our refusing to do so in its progress. Cold, unpleasant 
at first, is often refreshing and sanative, and is commonly allowable 
when the gastric symptoms predominate ; but it must be withheld if 
the lungs or their membranes are inflamed. The stomach, originally 
but little affected, may, in a week's time, suffer under gastritis, 
and require free leeching. The quinine which we give to-day 
from a belief that the stage is reached in which it will be useful, 
may still disagree with the patient; but we must not on that ac- 
count be backward in giving this medicine two days or even 
another day hence. If there be any notable change in the symp- 
toms, purgatives, proper in the beginning of typhus, will oftener, if 
persisted in, prove injurious irritants, and yet, towards the latter 
stage, they may give a salutary turn and seem to produce a crisis in 
the disease. During a period of ten days, I have, in some cases of 
typhoid fever, trusted entirely to simple cold or tepid water enemata, 
which served both to abate the morbid heat of the abdomen, and to 
procure a discharge once in the twenty-four hours from the bowels. 

But with whatever industry and judgment we may follow up the 
practice, the heads of which I have just sketched, typhus will still 
persist in its course, after a while to take a salutary turn towards 
recovery and health, or to assume a more and more aggravated and 



STATE OF THE HEART. 



515 



complicated character. Among the aggravations, will be depres- 
sion of the cerebral functions, such as stupor and coma, or dis- 
turbance manifested by delirium and increased frequency and 
weakness of the contractions of the heart ; whilst in the complica- 
tions will be ranked pulmonary congestion and bronchitis. On most 
of these points Dr. Stokes has already discoursed plausibly and 
well. There is one, however, on which he has elsewhere enlarged 
with more fulness and detail, and which, on account of its being so 
important a feature in the disease, merits attentive consideration. 
I refer now to the state of the heart in the later stages of typhus, 
which is in a measure made known to us by the rapid and feeble 
pulse ; but more fully indicated by auscultation, and in fatal cases 
by dissection. It has been long a familiar fact to those who had 
occasion to treat typhous fever with stimulants, that the best mea- 
sure of their beneficial operation was a diminished frequency and 
greater fulness of the pulse ; and that, on the contrary, if the pulse 
became more frequent and smaller, the use of this class of medi- 
cines was to be discontinued, and the augury of the case was at the 
same time commonly unfavourable. I well remember to have 
heard of, though I cannot say that I actually witnessed, enormous 
quantities of diffusible stimulants, such as brandy and wine, being 
used in the latter stages even of the remittent fever in Virginia, which 
in this period is commonly designated as typhus. Except to a 
physician who has had actual experience on the subject, the tolera- 
tion of the sanguiferous 'and nervous systems to such large quan- 
tities of wine and ardent spirits and carbonate of ammonia would be 
absolutely incredible. Once more, after a period which I would fain 
not consider very long, for it is included within my own professional 
observation, we find the practice of the free use of diffusible stimu- 
lants in certain forms and stages of typhus to be renewed, and pre- 
cisely after the same indication as before, to rouse and strengthen a 
weakened, heart and prostrated nervous system; and persevered in 
for the same reason, viz., a change of the pulse to slower and 
fuller. Now, however, that it is in our power to take more accu- 
rate measure of the real state of the heart by means of the stetho- 
scope, we shall be able to define with more nicety the indication 
for the use of stimulants, as well as for their discontinuance, than 
when we formed our opinion of the heart entirely from the signs 
furnished by the pulse. It has been the good fortune of Dr. Stokes 
to give a complete practical application of the general theory of a 
weakened circulation, and especially of a weakened heart, in 
typhous fever. His views and cases in illustration are to be found 
in the Dublin Journal of Medical Science for March, 1839.* 

" In typhous fever," as Dr. Stokes remarks, " two opposite con- 
ditions of the heart may be observed ; in the one the impulse be- 
comes extremely feeble, or altogether wanting, while the sounds 



* Republished in the American Medical Library for 1840. 



516 



TYPHOUS FEVER. 



are greatly diminished in intensity ; while in the other the heart's 
action and sounds continue vigorous throughout the whole course 
of the disease. 

" These opposite states are not necessarily revealed by the state 
of the pulse or the warmth of the surface. We may observe a hot 
skin, while the action of the heart is almost imperceptible, and on 
the other hand a patient may be pulseless, cold and livid for days 
together, while the heart is acting with the greatest vigour. 

" The condition of the heart must be determined by the applica- 
tion of the hand and stethoscope to the infra-mammary and sternal 
regions." 

The cardiac phenomena in one of the many cases recorded in 
the paper just quoted, are thus described. There was observed in 
the first place a progressively diminishing impulse; on the second 
day the impulse was visible at the side, but on the tenth was alto- 
gether wanting; it reappears on the twelfth, and continues to in- 
crease until the period of the patient's restoration to health. 

" In the second place we find a singular modification of the 
sounds of the heart ; the proportion between the two sounds was 
lost on the seventh day, the first being exceedingly feeble, the 
second comparatively strong; on the eighth day the first sound 
was scarcely audible, and on the tenth it became extinct, and we 
had the singular phenomenon never before observed, of the heart in 
typhous fever giving but a single sound. On the eleventh day, 
under the influence of powerful stimulation, the first sound re- 
appears and the second has more vigour ; on the twelfth day both 
sounds are distinctly audible, and on the fourteenth the phenomena 
of the heart are natural." 

The cardiac phenomena in typhous fever, as noticed and recorded 
by Dr. Stokes, are — 1. Impulse and sounds remaining unaltered ; 
the action of the heart corresponding with that of the pulse. 
2. Vigorous impulse, with distinct and proportionate sounds, with 
absence of pulse for many days. 3. Diminution of both sounds of 
the heart with absence or great diminution of the impulse (fetal 
character). 4. Diminution of the first sound, with cessation or great 
feebleness of the impulse. 5. Complete extinction of the first sound, 
the second remaining clear. 6. Predominance of the first sound, 
the second being extremely feeble. Of these the fourth and fifth 
were the most common. 

In a great majority of cases the phenomena were as follows : 
I. Diminished impulse. II. Diminished first sound, particularly of 
the left cavities. 

In most cases, considered through the whole progress, the dimi- 
nution and return of the first sound were accompanied with a di- 
minution and return of the impulse. But in some instances at 
particular periods of the case, this accordance between the impulse 
and sound did not exist. 

Doctor Stokes, after introducing some observations of Laennec 



I 

I 

SOFTENING OF THE LEFT VENTRICLE. 517 

( and Louis respecting the softening of the left side of the heart in 
fever, tells us, he has no doubt that the cause of the want of impulse, 
and feebleness or cessation of the first sound is a softening of the 
heart. It will be remembered that the observations of M. Louis 
I were made on the hearts of those who died of typhoid fever (p. 101 
of this volume), and those of Dr. Stokes apply to typhous fever ; 
thus furnishing additional proof in favour of the general sameness 
i of the two diseases, or rather of our regarding them as varieties of 
i the same disease. Dr. Stokes's proposition in favour of the organic 
I cause of the symptoms above mentioned are thus stated : 

I. Softening of the heart exists in typhous fever as a local dis- 
I ease, and without any analogous condition of the muscles of volun- 
tary life. 

II. In the dissections in the last epidemic, this softening of the 
heart was met with in cases which during life had presented the 

1 phenomena in question. 

j ' III. The physical signs indicate a debility of the left ventricle 
; principally, and it is the portion of the organ which is most often 

altered in consistence. 

IV. Laennec has stated that, in proportion to the severity of the 

putrescent phenomena is the liability to softening of the heart. And 
j the same observation is found to be true of the physical signs now 
j described. 

The farther analogy which the typhus bears to poisoning is exhi- 
bited in this peculiar impression on the heart — an effect which, on 
the authority of Orfila and others, is produced by the ingestion of 
arsenic. 

If this softening of the heart be one of the secondary diseases of 
typhus, we should, Dr. Stokes thinks, observe something like perio- 
dicity in its phenomena, as in the case of other lesions. It should 
appear at a certain time, and decline after its proper period expired. 
On an analysis of his cases, with a view to these points, the result 
was that in most instances the signs of diminished impulse and of 
first sound were developed at or about the sixth day, and the heart 
seemed healthy at or about the fourteenth day. 

The practical inference from these several facts is that in the 
diminished impulse, and in the feebleness or extinction of the first 
sound, we have a new, direct, and important indication for the use 

i of wine in typhous fever. In some cases, continues Dr. Stokes, the 
existence of these phenomena at an early period of the disease led 
us to anticipate the bad symptoms, and to commence in good time 

! the use of the great remedy ; and in others, notwithstanding the 
existence of some visceral irritation, the use of stimulants has been 

! adopted with the best success from the same indication. 

I The following case, as recorded in Dr, Stokes's paper, will con- 

i vey a clear idea of the connexion between the pathological pheno- 

I mena and the progress of the disease, as also the indications which 

j they furnished for the use of stimulants. 



i 



518 



TYPHOUS FEVER. 



Petechial fever, with bronchitis and diarrhoea — Vigorous action of the heart up to the 
ninth day — Preponderance of the first sound on the sixteenth day — Use of wine — 
Recovery. 

Thomas Keefe, set. 30, a strong muscular man, was admitted on 
the 11th May, being then nine days ill; he was abundantly mascu- 
lated; well marked bronchitic rales in both lungs; the action of the 
heart was vigorous, and both the sounds natural; pulse 108, full. 
The chest was cupped and blistered, and pills of blue pill and ipe- 
cacuanha exhibited. 



DATE. 

May 13. 



GENERAL SYMPTOMS. 

Severe diarrhoea. 



PHENOMENA OF CIRCULATION. TREATMENT. 

Pulse strong; both sounds Omit the 

are distinct and proportion- pills ; poul- 

ate, but they seem as if dis- tices to the 

tant. abdomen. 



" 14. The diarrhoea continues ; 
maculae abundant and 
florid. 



Sounds of the heart more Saline mix- 
feeble ; the impulse is im- ture ; arrow 
perceptible except at the termi- root, 
nation of expiration ; pulse 
100, strong. 



" 15. 



The bronchitis is more 
severe. 



Impulse quite impercep- 
tible ; both sounds feeble 
but distinct; pulse 100, 
feeble. 



Wine 6 oz.; 
dry cupping 
blister to the 
chest ; pills 
of ipecacuan. 
hyosciamus, 
and carb. am- 
monia. 



16. Pupils contracted ; bron- 
chitis continues ; tongue 
glazed and red. 



Impulse imperceptible ; 
sounds as before ; pulse 92, 
a shade stronger than yes- 
terday. 



Wine 12oz.; 
beef tea ; an- 
timonial mix- 
ture, with 3 
grains of tart, 
emet. 



17. Some diarrhoea ; no 
vomiting ; bronchitis di- 
minished ; the petechia? 
are not more livid ; pupils 
less contracted ; tongue 
improving, becoming moist 
and pale at the edges ; 
the wine was given warm. 



Impulse again perceptible ; 
pulse 82 ; both sounds of the 
heart can be heard. 



Wine 10oz.; 
senega mix- 
lure ; musk 
and camphor, 
pills. 



18. Tongue improving 
techiae fading. 



pe- 



1 9. Slept well ; diarrhoea con- 
tinues. 



Sounds of the heart not so 
distinct as yesterday ; the se- 
cond can scarcely be heard ; 
impulse perceptible. 

Sounds as yesterday ; im- 
pulse imperceptible. 



Repeat all. 



Wine 10oz.; 
blister to the 
heart ; bark 
mixture. 



"21. General improvement; 
slept well ; perspiration. 



Both sounds can no-w be 
heard ; they are feeble but 
proportionate; impulse im- 
perceptible ; pulse 72. 



Wine 8 oz.; 
repeat the 
mixture. 



INDICATIONS FOR THE USE OF WINE. 519 



BATE. GENERAL SYMPTOMS. 

" 22. Improvement continues. 



PHENOMENA OF CIRCULATION". TREATMENT. 

The sounds over the right Repeat all. 
cavities are proportionate ; 

over the left the first is much 
more feeble than the second ; 
no impulse. 



"23. Skin cool ; appetite good; First sound much more Wine 4 oz. 
no bronchial rales. distinct , impulse plainly per- 

ceptible ; pulse 72. 

Convalescent." 

Important as is the guide thus furnished by the state of the heart 
for the use of stimulants, it may not be in the power of all without 
some experience to avail of it. The practitioner will, therefore, do 
well to attend to the following points as directed by Dr. Armstrong, 
in forming his opinion of the propriety of persevering in the admi- 
nistration of wine to a patient in typhous fever. 

1. If the tongue become more dry and baked, it generally does 
harm ; if it become moist, it generally does good. 

2. If the pulse becomes quicker, it does harm : if it be rendered 
slower, it does good. 

3. If the skin become hot and parched, it does harm ; if it be- 
come more comfortably moist, it does good. 

4. If the breathing become more hurried, it does harm ; if it be- 
come more deep and slow, it does good. 

5. If the patient become more and more restless, it does harm ; 
if he become more and more tranquil, it does good. 

You must be cautious in observing its effects ; and till you see 
which way they tend, you should give it only in teaspoonfuls. 

Harmonizing well with wine at this stage of typhous fever is 
quinine, in the prescribing and continuing the use of which we must 
be guided by nearly the same rules with those which regulate us 
in that of the former remedy. 

One advantage, and a great one, which, it seems to me, wine 
possesses at this time, and it may be added in the advanced stages 
of many diseases, over more potent stimulants, is in its beneficial 
action on nutritive life, which is in these cases very low, and the ex- 
treme depression of which will alone kill. At particular epocha in 
febrile diseases we have more to apprehend from nutrititive debility 
than from the disorganization of an important organ or functional tis- 
sue. Under this impression w ? e ought to watch the very first calls made 
by the system for mild nutriment, and administer it accordingly in 
the form of sago, or arrow root, or panada to which a certain por- 
! tion of wine is added. Fulfilling the ends both of a medicinal and 
j nutritive stimulus, wine whey is often an admirable aid at this time. 

I have frequently, I am sure, preserved life for days by this article, 
! towards the termination of diseases, phthisis pulmonalis for example, 
j necessarily fatal. If one is not sure of the quality of the wine, or 
I if it is not readily procurable, it will be better to turn the milk by 
an acid, and then add to the whey thus made a portion of spirits — 



520 



TYPHOUS FEVER. 



brandy or rum, &c. Milk punch, a favourite prescription with 
some physicians, is objectionable in many cases on account of the 
milk being oppressive to an enfeebled stomach, and not readily 
disposed of by absorption and subsequent action on the excretory 
organs, particularly the skin and kidneys, as whey is. 

A cautionary advice should be added by the physician who re- 
commends stimulants of this kind — wine and distilled spirits, — to be 
given to his patient. It is; not to confound their occasionally curative 
powers in some extreme cases of disease with their effects when 
used habitually. Opium, quinine, arsenic itself, are given in disease, 
but the fact furnishes no argument for their daily use by a person in 
health. In the one case as in the other, a medicine thus regularly 
used in a common state of the animal oeconomy becomes a poison; 
and it is doubtful whether this principle would be more clearly 
demonstrated by the habitual use of arsenic than it is by that of 
brandy, or rum, or whiskey. 

There is one remark which I have to make on the preceding 
views and deductions of Dr. Stokes. It is, that, although the prin- 
ciple which he inculcates is exceedingly valuable and susceptible of 
demonstration and practical application, not only in typhus but in 
other forms of fever, yet the practitioner, in the country especially, 
who may have to treat sporadic cases only of typhus, or others of 
a typhoid character, must not expect to find the heart lesed, and its 
function enfeebled to such an extent as that pointed out by Dr. 
Stokes, and which is so common in the typhus occurring in a 
crowded and destitute population, and especially in that which is 
met with in the hospitals. The air of a hospital speedily displays 
its deteriorating and depressing effect on all the functions, and 
greatly increases the tendency to a softening and loss of tone of 
the solids and analogous changes in the blood. 

Notwithstanding the extension of this lecture on typhous fever 
beyond what I had anticipated, I must, ere.I conclude, notice what 
may be called the antimonial or rather the tartar emetic practice 
in this disease. Rasori, the founder of the new Italian medical 
doctrine of counter-stimulus, was in the habit of administering tar- 
tar emetic in quantities of four, six, or eight grains duringlhe 
twenty-four hours, in an epidemic petechial typhus which prevailed 
in Genoa when it was besieged by the Austrians in 1799. He 
gave it in w r ater, flavoured with substances most agreeable to 
the patient, but most commonly with cream of tartar. As he informs 
us in his treatise (Storia della Febbre Epidemica di Genova) some- 
times venesection preceded the administration of the tartar emetic. 
He continued the medicine from the beginning of the disease on to con- 
valescence — not as a novice in a knowledge of the operation of anti- il 
mony on the system might suppose, by vomiting and nauseating, ij 
and perhaps also purging, his patient all this time. Not at all — the ,: 
effects of the medicine were manifested in a gradual abatement of j 
the febrile disturbance; generally without vomiting or purging, or i\ 



USE OF TARTAR EMETIC BY RASORI. 



521 



any evacuation. Rasori records, among others, the case of a 
young man, of a robust habit of body, seized with the fever, to whom 
he gave during the first day four grains, and afterwards increased 
the quantity until sixteen grains of the tartar emetic had been taken, 
without any evacuation either by the mouth or from the rectum 
resulting. A purgative enema was then given, which was returned 
without the addition of any fecal matter: but the patient's condition 
was soon ameliorated, and a continuation of the medicine in smaller 
doses restored him to health in a week. Another case was that of 
a young goldsmith, also of a robust habit, who on the first com- 
ing on of the fever was seized with violent delirium, which after 
a few days was followed by a profound stupor, so as to prevent his 
taking anything whatever by the mouth. Enemata were, there- 
fore, administered ; a single one of which contained half an ounce 
i of nitre and sixteen grains of tartar emetic : but no discharge 
I from the bowels took place until after the fourth clyster, to 
w 7 hich an ounce of common salt had been added. The enemata 
were continued without the salt, and according to custom caused 
! no evacuation ; to produce which, when it was desired, it was al- 
! ways necessary to add the salt. Under this treatment the stupor 
ceased about the eleventh day. From this time the patient made 
use, daily, of a lemonade in which six grains of tartar emetic had been 
dissolved, but still without the latter causing any discharge, which, 
however, was obtained from time to time by the enemata as before. 
After three weeks the disease took a favourable turn, and the cure 
| was completed with small doses of nitre and tartar emetic. 

How far this practice of Rasori may have suggested to Dr. Graves 
! that which I am about to describe, is not a matter of any moment. 
It is with the result that we have to do more than with the means 
by which the former was reached. The distinguished Dublin 
physician, an ornament of a city which can now boast of so many 
celebrated men in all the departments of medicine, prescribed tartar 
emetic in delirium tremens, from a belief that the preparations of anti- 
mony have a distinct narcotic effect, and because he had seen 
patients in fever whose watchfulness had been removed by anti- 
mony given in the form of tartar emetic or James's powder. " Our 
! predecessors," he observes, " were much in the habit of using anti* 
monial mixtures in the treatment of fever ; and they did this because 
they knew, by experience, that these remedies worked well." 

In subsequent clinical lectures, Dr. Graves explicitly describes 
the symptoms in continued fever, which indicate the propriety of 
| using the tartar emetic. In some cases the patient has reached, 
i we will suppose, the third day of the fever, and has now a flushed 
| face, and headache ; his pulse is from 100 to 110, but not remarka- 
, bly strong. He is, also, found to be sweating profusely from the 
! commencement of his illness, but without any proportionate relief 
j to his symptoms ; and he is, moreover, restless and watchful. This 
patient may have no epigastric tenderness, no cough, no sign of 
local disease in either the thoracic or abdominal cavities ; he has 

45 



522 



TYPHOUS FEVER. 



been purged, used diaphoretics, and perhaps mercurials ; every atten- 
tion has been paid to regimen, ventilation, and cleanliness ; but still 
he lies there in a state of undiminished febrile excitement, with 
persistent headache, quickness of pulse, and sleeplessness. In a 
case of this nature, Dr. Graves has directed venesection, which was 
performed with some relief, and without increasing the debility. 
After this he proposed to give the patient large doses of tartar 
emetic; and it was accordingly taken in the quantity and mode 
in which it is, generally prescribed in acute pneumonia ; that is to 
say, six grains of tartar emetic combined with a little mucilage and 
cinnamon water in an eight-ounce mixture, to be taken in the course 
of twenty-four hours. After taking five or six grains, the sweating 
began to diminish ; on the second day he scarcely perspired any, and 
his headache was greatly relieved; he began to improve rapidly in 
every respect, sleep returned, nervous agitation ceased, and con- 
valescence became soon established. In another case in which, after 
a period of eight or nine days of fever unaccompanied by any 
peculiarity, except that the patient was very nervous and alarmed 
about his situation, cerebral symptoms of a violent kind supervened 
with a rising of the pulse. Leeches had been repeatedly applied 
to the head, and cold lotions afterwards, and he was purged freely and 
often. Under these circumstances, says Dr. Graves, " I advised the 
use of large doses of tartar emetic in the mode already detailed, 
except that, in this case, in consequence of the violence of the de- 
lirium, I ordered the quantity prescribed for a dose to be taken every 
hour instead of every second hour. The patient took about ten or 
twelve grains during the course of the night, and next day his de- 
lirium had almost completely subsided. Under the use of this 
remedy he became quite calm, fell into a sound sleep, and began to 
recover rapidly." 

Another still more alarming and almost hopeless case is related by 
Dr. Graves, in which, notwithstanding the most carefully devised treat- 
ment, the fifteenth day of the fever was reached, and the patient was 
in the following state: — "He had universal tremors and subsultus ten- 
dinum, his eye was suffused and restless, he had been lying for some 
days entirely on his back, his tongue was dry and black, his belly 
tympanitic, his pulse 140, quick and steady, his delirium w T as chiefly 
exhibited in short, broken sentences and in a subdued tone of voice ; 
and it was now eight days and nights since he had slept." Blisters 
to the nape of the neck, cold applications and purgatives had failed ; 
opium in various forms had been tried without the slightest benefit; 
if sleep was not speedil v obtained he was lost. After mature con- 
sultation between Drs. Graves and Stokes, it was agreed that the 
suggestion of the former should be carried out, by administering to 
the patient a combination of tartar emetic and laudanum in the fol- 
lowing form, which is that in which Dr. G. generally employs these 
remedies in the treatment of delirium tremens. R. Tart, antimon. 
gr. iv., Tinct. opii. Ji., Mist, camphor § viii. M. Of this mixture a 
tablespoonful was taken every second hour. " The success of this 



DR. GRAVES'S USE OF TARTAR EMETIC. 



523 



was almost magical. It is true that it vomited him ; after taking 
the second dose he threw up a large quantity of bile, but it did him 
no harm. After the third or fourth dose he fell asleep, and awoke 
calm and refreshed ; he began to improve rapidly and soon re- 
covered." 

The simple announcement that a particular medicine is beneficial 
in a disease is apt to mislead, unless the chief circumstances under 
| which the remedy should be administered are also distinctly defined 
I and the occasional embarrassment in the case noted at the same 
time. For this reason, and in justice to Dr. Graves as well as to 
| those of you who may desire to imitate his practice, I shall give 
I one more picture of the symptoms for the removal of which this 
! gentleman believes the tartar emetic to be available. On this point 
i he thus discourses in a lecture on the spotted fever epidemic in 
Dublin in 1834-5: — " I wish you clearly to understand, that, after 
the headache and cerebral excitement which accompanied the very 
commencement of the fever had been subdued, or had ceased; after 
; sleep and calm had returned, and had continued for many days, 
then a new order of things commenced ; subsultus, watchfulness, 
: muttering, raving, involuntary discharges, &c, all denoted great 
derangement of the nervous system ; but still there was no proof 
that this derangement depended on cerebral congestion. After a 
few, or after many days, however, unequivocal symptoms of the 
latter set in; the face and eyes became suffused and flushed; the 
pupils manifested a tendency to become contracted, and occasion- 
' ally convulsions took place; the patient became totally sleepless. 
When the latter and dangerous period of the fever was accompanied 
by the former nervous group of symptoms alone, they yielded to 
wine, musk, porter, and opiates; but when the symptoms indicating 
cerebral congestion were superadded, then it was that the case 
assumed so great and striking a similarity, so far as the functions 
of the nervous system were concerned, to the well known variety 
of delirium tremens accompanied by cerebral congestion, — to that 
variety of delirium tremens, in fact, which can only be successfully 
treated by the judicious but bold exhibition of tartar emetic com- 
bined with laudanum." 

Dr. Graves claims the discovery of the utility of this practice in 
the advanced stages of spotted fever as peculiarly his own. I 
, could wish that he had not added the assertion, " for there is not, in 
the writing of any author on the subject, the slightest trace of such 
a method to be found. " The lecturer had at the moment forgot- 
ten the practice pursued by Rasori more than thirty years before, 
a sketch of which I have already given, and which certainly ex- 
! hibits something more than 4 the slightest trace' of Dr. Graves's 
I method — in spotted fever, too. Even the administration of tartar 
i emetic in an enema, as extolled by this gentleman in cases of deli- 
! rium occurring in the progress of fever, was directed by Rasori 
I under similar circumstances, in the case which I have already 
I detailed. Two or three srrains of this salt are recommended by 



524 



TYPHOUS FEVER. 



Dr. Graves to be dissolved in four or five ounces of mucilage of 
starch or isinglass, and to be injected with the end of a long flexi- 
ble tube, so as to make the contents of the syringe pass high up 
into the bowel. " Jn this way you can secure all the good effects 
of tartarized antimony in overcoming the congestion of the brain, 
and procuring sleep." 

In some of the more desperate cases of fever in which cerebral 
symptoms predominate, as well as in other cases of hydrocephalus, 
Dr. Graves has directed, with happy effect, tartar emetic ointment 
to be rubbed over the shaven and subsequently blistered, scalp — 
painful and violent inflammation results, and a removal of the worst 
symptoms. 

The troublesome thirst in fever, which is now so generally and pro- 
perly counteracted by cool and often cold and iced drinks, is often still 
more effectually subdued by a slight bitter infusion to which a little 
mineral acid has been added than by large aqueous potations alone. 

In taking a survey of the whole subject of fever, its proteiform 
features, and the multifarious and often contradictory remedies, 
not to say plans of treatment, which have been at different times, 
employed for its cure, we may, indeed must display, a whole- 
some scepticism of the extraordinary results attributed to the 
enforcement of the rules of art; the more especially so when w r e 
find on record so many instances of cures accomplished by nature, 
and nature sometimes crossed too by popular ignorance and 
superstition. A passage in a paper just now before me, (my ac- 
count of the Contagious Fever in Italy, in 1817,) will come in ap- 
propriately in illustration of this truth. " To prove how much 
nature is capable of performing, and to what extent we should rely 
on her exertions, Valentini says, that in a great number of cases of 
this fever, he has administered nothing but copious drinks either of 
pure water or of lemonade, or of nitrous emulsion. He cites, as a 
proof of the efficacy of this plan, the cure of a soldier in the Ponti- 
fical service, thirty-three years of age and of a robust habit, who 
was seized with the gastric-nervous fever. This man obstinately 
refused all medicines except an emetic which had been given at 
the commencement of the disease, yet by his drinking simple 
lemonade, and abundance of the purest water, after having suffered 
the attack of mortal symptoms, on the seventeenth day of the dis- 
ease he fell into a copious sweat and recovered. I was pursuaded, 
continues Valentini, of the inefficacy of medicine in the greater 
number of cases, and willingly followed the wishes of the patient. 
He supports his opinions by referring to Hippocrates and others of 
the ancient as well as modern writers ; and concludes by a quota- 
tion from Celsus, in which this author says : " Multi magni morbi 
curantur abstinentid et quiete. " 



CONGESTIVE NOT A NEW FEVER. 



525 



LECTURE II. 

Congestive fever — Is not a new disease — Restricted notions on the subject — Congestion 
an effect of irregular circulation — Is symptomatic of various nervous disorders — Con- 
gestion associated with intermittent, remittent, and typhous fevers — Each of these in 
one of its stages is complicated with congestion — May be associated with inflam- 
mation, but not dependent on it — Same of congestion and hemorrhage — What is the 
actual state of the sanguiferous system in congestion — Capillaries act an important 
part in congestion, — and they in turn are modified by the state of the nervous system 
— Excellent descriptions of congestive intermittent and remittent fevers by European 
writers — Torti — Alibert — Senac, his views and cases — Lind, his cases — Clark, his 
cases and description of Bengal fever — Johnson on the state of the viscera — Shields 
on the Batavia fever. 

Is it a better pathology or a change in the character of the disease 
which has caused so generally of late years the substitution of conges- 
tive for bilious remittent fever by our physicians in the south and 
west? Both causes have probably operated in bringing about the 
change of nomenclature ; — although as yet there is not, I fear, a due 
appreciation either of the circumstances under which congestive 
fever has become more common, or of the real nature of the pre- 
cursory and actual symptoms of the disease. The vast extent of 
new country in the United States which has been occupied, of late 
years, with a view to agricultural improvement includes regions, the 
localities and climate of which furnish the atmospherical or remote 
causes, whilst the labour and personal exposure of the new tenants of 
the soil are so many direct and exciting ones of fever, the dominant 
type of which is designated by the term congestive. Unhappily, the 
profession has not been benefitted in any adequate degree by the great 
amount and intensity of febrile disease forced on the attention of so 
many medical men in so many different parts of the United States. 
If we look at the records of fever in our own medical journals we 
may seek in vain for clear and connected histories of the progressive 
changes by which the old fashioned bilious remittent fever has been 
gradually yielding to the more recent congestive one. I say recent 
in reference to progress of opinion and the nomenclature among us, 
— but not in other parts of the world. Is it the pride of opinion or 
ignorance which prompts each neophyte to embody a doctrine of his 
own on this subject, the result often of the most superficial observa- 
tion as it is itself evidence of the shallowest reasoning? There is 
hardly any person so little desirous as I am of making a parade of 
learning myself, or so little prone to admire it in others. Hence, in 
these lectures I carefully abstain from references or citations which 
are not, in my opinion at least, cognate to the subject, and aids in its 
enforcement or illustration. But, on the present occasion, I cannot 
I express my regret at the superficial views taken and ignorance ma- 
nifested of our country fevers which assume the congestive form, 
without directly showing the numerous sources of better knowledge 
opened to us in the works of the great departed,; — of those whose 
names at least, one must suppose, are occasionally uttered in the 

45* 



526 



CONGESTIVE FEVER. 



hearing of medical students. In a medical journal, of a date a few 
years back, I have lately read the communication of a young prac- 
titioner, who relates with great naivete his persistence in the use of 
calomel in large doses, and active purgatives unto the death, in 
several cases of intermittent fever. His object in writing was to 
show that purgatives alone would not cure the fever which he had 
to treat, and inferentially that the contrary, as taught by his pro- 
fessor, was incorrect. This person believed, no doubt, that he was 
not to blame in practising medicine in entire ignorance of some of 
its common elements, because they either had not been taught or 
had been overlooked by his speculative professor; and that after 
letting several patients die of a readily curable disease he had 
made a kind of discovery, thus expressed: "When the fever 
appears in the form of an intermittent, the treatment should be 
varied with respect to the usual time for the chill, and to the general 
circumstances connected with the case." I shall not now inquire 
into the probability or folly of any hypothesis wherever taught, and 
advert to this case not to censure teachers for dogmatism and ex- 
clusiveness, although these are censurable, but for their not putting 
their students in the path of study and inquiry. Young graduates 
themselves are reprehensible, if they have such excessively restricted 
notions of the science of medicine and of the diversified practical 
application of this science, as to suppose that an imperfect recollec- 
tion of the lectures of their professors, or a few rough notes of these 
lectures, is an adequate intellectual stock for the great enterprise in 
which they are about to engage. It is but a short step beyond this 
line of confidence in such feeble counsel to that self sufficiency which 
constitutes the great feature of empiricism, and which, impliedly at 
least, impels its possessor to claim an intuitive knowledge of 
medicine. 

There is not, properly, any fever characterized by congestion in 
contrast with another which is without it. Congestion, simply an 
accumulation and temporary retention of fluids and chiefly blood in 
an organ, is often no disease at all; it occurs in the uterus prior to 
menstruation and during pregnancy, and in the mammae prior to 
lactation, and also, in the muscles and lungs, liver and spleen, 
during very active exercise, and probably in the brain during 
sleep. 

Congestion of a morbid kind is common in nearly all fevers, 
intermittent, remittent and continued : it will accompany winter 
epidemics, in which the thoracic organs are the chief sufferers, and 
summer and autumnal ones, in which the greatest lesions are in the 
abdominal viscera and brain : it is not limited to any organ, — some- 
times being most manifest in the brain, sometimes in the lungs, and 
often in the liver and spleen, or even kidneys. Congestion may be 
created by an afflux of fluids to a part in consequence of a simple in- 
crease of sensibility; as in the skin after high heat, friction, or insola- 
tion, in the mucous membranes after nervous stimulants, &c. Strong 
innervation, in which the nervous centres are much excited, as under 



CONGESTION WITHOUT INFLAMMATION. 527 



various emotions, will produce congestion at one time of the brain at 
another of the lungs or liver. Certain nervous affections, as hyste- 
ria, will give rise to irregular determination and retardation of blood ; 
in fact, congestion of an organ, which, like that of a physiological 
kind, often entirely disappears after the removal of the nervous dis- 
turbance. Under nervous derangemeni of this kind we sometimes 
meet with the phenomena of coma, catalepsy, somnambulism, 
paralysis, tetanus and convulsions, and other diseases of animal life, 
and icy coldness or excessive heat, fulness and throbbing, dysp- 
noea, vomiting, hiccup, colic, hemorrhages, tympanites, ischuria, 
diarrhoea, &c, in organic life. With many of these nervous affec- 
tions congestion is associated ; sometimes preceding, sometimes 
remaining after the disappearance of the more obvious and violent 
symptoms. 

Congestion may precede or follow inflammation, but without ac- 
knowledging this latter as its cause. It may also be accompanied 
with a retention of muscular strength, or with extreme debility and 
prostration. I was much impressed with an evidence of the former 
combination in the case of a large muscular Scotchman, a deserter 
! from the British fleet during the last war, who found his way to 
Winchester, Va., and was there seized with the epidemic which 
j went by so many names-^-the chief of which were typhus pleurisy 
and typhus pneumonia. This man, whom I saw about ten o'clock 
j in the morning, after the earlier visit and prescription of my pre- 
I ceptor, could not then be kept in bed ; he paced up and down the 
! room with a firm step, making every now and then allusions to his 
recent escape and without any fear about his recovery. At my 
next visit, in less than two hours afterwards, the patient was a 
corpse. The differences in the degree of muscular strength or in 
the activity of the circulation are seldom dependent on or expli- 
cable by the extent of the congestion ; but rather on the extent of the 
prior and accompanying impression made on the nervous system. 
In the case just referred to, the congestion of the lungs was not ac- 
companied by any notable sedative action on the nervous system — 
whereas at the onset of certain fevers, this system which had been 
commonly for some time before exposed to a slow but violent seda- 
tion, is now in a temporary palsy, and hence the languor and ina- 
bility to move. Duration of the congestion will give a tolerable 
measure of its character, that is, of its dependence on simple nervous 
excitement, or on inflammation. If it depends merely on nervous 
disorder, it is irregular in its appearance, and commonly, indeed 
i distinctly, periodical; as we see in all the disturbances of the cir- 
culation and accumulations in particular organs. But if the con- 
! gestion be permanent, or if it have supervened on a permanent 
j disorder of function, we may infer that it depends on an abiding 
! cause, which is inflammation. These two kinds of congestion are 
I often manifested, the first in the inception, and the second in the lat- 
| ter stage of fever. The drowsiness, the obtuseness of senses and 
bewilderment, are evidences of congested brain at the beginning of 



528 



CONGESTIVE FEVER. 



the fever ; but, as simply the result of nervous depression, they soon 
disappear with the reaction. Similar disturbances of function at 
the conclusion of the disease are more generally brought on by 
the congestion, which is renewed and maintained by meningitis or 
encephalitis. 

Congestion is commonly associated in the minds, I believe, of 
most physicians with symptoms of want of action at the surface of 
the body and extremities, and by a kind of collapse of the capillaries. 
Cholera, dysentery, and some other abdominal diseases, afford ex- 
amples of this kind, as do some of the attacks of the lungs in the 
winter season which occur in the old and intemperate, who may 
have been long exposed to the inclemency of the weather. But 
there are other forms of congestion, as of that of the brain and 
lungs from sun-stroke, in w 7 hich the external heat, and morbid action 
of the capillaries is excessive. In pulmonary congestion, espe- 
cially that which was so common in the winter epidemic already 
referred to, I was struck with the not unfrequent occurrence of a 
profuse watery and warm sweat in the very last and fatal stage of 
the disease. The boatswain who walked about his room until 
almost at the point of death had, I well remember, these symptoms. 
I was called early in the morning, some years ago, to visit a man, 
whom I found in all the horrors of cerebral congestion and convul- 
sions, which were ended in an hour afterwards by death. He had 
retired to rest the preceding night, after a supper of mush and milk, 
and a pediluvium of cold water. Early in the morning he awoke 
some persons in the room beneath him by delirious efforts, as if he 
wished to bail out a boat. He had been a fisherman and of in- 
temperate habits, much exposed to the sun during the preceding 
week, and on two different occasions had suffered from a sun-stroke. 
On dissection, the arachnoid v/as found to be thickened and 
covered with fluid, which also filled the ventricles; the pia mater 
was injected in patches, and its larger vessels turgid. The mucous 
membrane of the stomach and small intestines were deeply injected 
in different parts, and the liver was much engorged. Here is an in- 
stance of congestion of the brain supervening on prior inflammation of 
the arachnoid; and that of the liver, though this is less certain, 
following that of the gastro-enteric mucous membrane. But the 
pointto which I wish more immediately to direct your attention, is the 
high and diffused heat of the surface in this case, which remained 
many hours after death. I have seen, I think in the same summer, a 
person perish in nearly a similar manner from cerebral and pulmo- 
nary congestion, whose skin just before death was intensely hot, 
especially over the chest and abdomen. In the persons suffering 
from sun-stroke, a common accompaniment of the mortal symp- 
toms, and which I have noted at different times, is this acrid heat 
of the skin, which repeated cold affusion will sometimes hardly 
abate. Here, together with abdominal and cerebral congestion, 
there is an atony of the capillaries ; not that of collapse, but that 
succeeding to inordinate excitement, caused by the sustained stimu- 
lus of high heat to the skin and lungs. 



CONGESTION A SYMPTOM. 529 

The physiological condition for congestion is simply repletion in 
excess of the vessels, which may amount to plethora, and dis- 
tention of the tissues of the part affected. Consequently, as must 
indeed by this time have been inferred, it may exist without any 
organic lesion or deviation of parts from their normal state; although 
at the same time it may so interfere with a function as to obliterate 
it, and even cause death. Thus, apoplexy is sometimes the conse- 
quence of mere cerebral congestion, without any rupture of vessels or 
effusion of fluid beyond its proper limits. In the lungs, nearly a 
similar state of the vascular system is occasionally met with, con- 
stituting pulmonary apoplexy, which will of itself kill without any 
notable alteration, by laceration or otherwise, of the pulmonary 
tissue or vessels. We discover not unfrequently proofs of the truth 
of this position in an entire disappearance of all the evidences, as 
they would be termed, of congestion just before death. The accu- 
mulated blood has passed from the arteries into the veins, leaving 
no sign of organic lesion. There is, for the same reason, no morbid 
product of congestion, if we except sometimes a sanguineous or 
serous exhalation, which does not, however, alter the intimate tex- 
ture, or transparency even, of the tissues. This coincidence of 
hemorrhage and serous effusion with-congestion, has induced some 
to believe erroneously, that the former morbid phenomena are ne- 
cessary consequences of the latter state; the more so, because the 
congestion is often relieved by the discharge of blood or serum, as 
the case may be. But there may be hemorrhage without congestion, 
or, still more frequently, there is congestion without hemorrhage. 
This remark will apply to the coincidences between congestion or 
local plethora in the liver, spleen or stomach, and vomiting and in- 
creased biliary discharge and other disturbances of secretion. The 
mere accumulation of blood, or the material for secretion, in the 
liver or the mesenteric circle, or in the kidneys, will not necessarily 
cause a greater secretion of bile, or of sero-mucous discharge from 
the intestines, or of urine, unless there have been an augmentation 
of nervous excitement in these organs, either by increase of general 
innervation, or by a new stimulus acting directly on the secreting 
surface of the organ, or of a surface with which, as in the case of 
the liver, it is in functional relation. How often do we not find the 
lungs dammed up with blood, but without any increase of pulmonary 
exhalation or of mucous secretion, and the liver gorged with blood, 
hardly giving out bile at all. 

I have hitherto restricted myself to a plain exhibition of the chief 
phenomena, direct and accompanying, of congestion, without any 
attempt at system ; but still, I hope, with the good effect of pre- 
paring you to understand better, or at least to receive at their true 
value the most marked symptoms of congestive fever. Beyond this 
line, however, it is no uncommon thing to pass, and to ask, if con- 
gestion be a temporary irregularity in the circulation, what is the 
state of the circulatory system itself, which is most favourable to 
congestion ? Is it augmented or diminished power — an accelerated 
or retarded action of the heart and vessels 1 Some have answered 



530 



CONGESTIVE FEVER. 



this question with due caution ; and allege that, when the heart con- 
tracts with more than its customary force and drives the blood in 
increased quantity into an organ or tissues, there is active con- 
gestion — but that when the blood is accumulated in the capillaries 
and veins, and obstruction is offered to its return into the right auricle 
and ventricle, by feebleness or organic disease of this side of the 
heart, there is then passive or venous congestion. This distinction 
is more plausible than true, as far as regards the phraseology by 
which it is expressed. In the first variety, the term active is ob- 
viously applied to the heart ; in the second, to the tissues and organs 
which are the seat of the congestion; If our terminology is to be 
derived from the real or presumed condition of the latter, the word 
passive is applicable in both cases ; for between the part which is 
unable to resist the impetus of arterial blood from the heart without 
its vessels and tissues yielding and becoming distended, that is con- 
gested, and another part which cannot pass on that which is re- 
ceived from the arteries, but allows it to be accumulated, that is 
congested, there is not really any notable difference ; certainly none 
which would justify the title of active in the former, and of passive 
in the latter. We might, it is true, contrast the phenomena resulting 
from hypertrophy of the left ventricle, by which the blood is sent out 
with increased force into all the organs, with a weakened state and 
valvular disease of the right auricle and ventricle, by which the blood 
retiring from all these organs was slowly brought away from the 
vena cava. But, in reference to congestion of an organ, the effect 
will depend more on the state of the capillaries, arterial and venous, 
and their interwoven nerves, than the excessive impetus of the vis a 
tergo, or the deficiency of it from the left ventricle. Of the effect of a 
local cause acting on the capillaries, and producing congestion of 
a part, we have a familiar example in what takes place after im- 
mersing the hand in iced water. At first, there is a diminution of 
the size of the hand ; the skin is shrunken and pallid, and sensation 
lost. On. withdrawing the hand, the skin becomes of a slight pur- 
ple, then a deep, and finally, a bright red colour; it isenlarged also, and 
there is a tingling sensation at the end of the fingers, showing the 
change which has taken place in the nerves, as well as the blood- 
vessels. The capillaries and adjoining vessels, which at first by 
their collapse from cold were unable to receive the blood from the 
larger arteries, have now resumed not only their former size, but 
they are actually dilated, and yield more than common to the im- 
petus of the blood, which they contain also in larger quantities and 
transmit slower than usual. In fine, thereis for a time a true con- 
gestion in the skin and teguments of the hand, which was thus im- 
mersed. Similar phenomena are evidenced on coming into a warm 
room, or approaching the hand to a fire after exposure to severe cold 
out of doors. Nervous depression would, therefore, seem to invite 
accumulation of blood, by the less ability given for its transmission; 
and in this way all strong sedative agents, whether atmospheric 
combinations which we cannot accurately define, or admitted 
poisons, are seen to give rise to congestions in various organs. But, 



AUTHORITIES ON CONGESTIVE FEVER. 



531 



as it is not my object to occupy your attention with anything like 

hypothesis, but merely to place before you some facts and views on 
; this subject, by which you will be better able to appreciate the 

narratives and descriptions of those who have written on congestive 
, fever, I shall, without farther introduction, proceed to this part of 

my duty. It will be seen that congestion is associated with inter- 
| mittent, remittent, and typhous fevers respectively, and gives these 
' a marked character. This is an important fact which it is incum- 
■ bent on you to be well acquainted with, in order that you may not, 
| like the young physician of whom I spoke at the beginning of this 
j lecture, be taken by surprise when the moment for decisive action 

arrives. 

The congestive fever of this country, and especially that of the 
western and southern states, is identical with the malignant or perni- 
cious remittents, or the intermittent ataxic fever of the writers of con- 
tinental Europe, and has been more particularly described by those of 
; Italy. In the great valley of the Po, in the hospitals of Milan, Pavia, 
Padua, Vicenza, and Venice, and in the adjoining country ; also in 
; the marshes from Pisa and Sienna to the sea, and in the Cam- 
l pagna de Roma and Pontine Marshes, cases are met with yearly 
of malignant intermittent and remittent fevers, such as were long 
ago so accurately described by Torti, Ramazzini, Rivierus, Lan- 
cisi, in former times, and Rubini, Giannini, Folchi, Bailly, and 
others, in our own day. Morton and Cleghorn, the latter deriving 
his experience from observations in Minorca, have contributed 
I valuable information to the same purport, which has been ampli- 
fied and extended by Lind, Pringle, Jackson, Johnson, Clarke, 
and numerous writers in medical journals. The list might be 
extended, but I refer to those now before me, and from some of 
which I will cull for your benefit. But let me not pass by unno- 
ticed the excellent work of Senac on Fever, translated by Dr. Cald- 
well, from the perusal of which I early in my medical studies derived 
so much profit, and the more ambitious but yet useful Alibert on 
Pernicious Fevers. 

The suddenness of the attack, the extreme postration and utter 
'> insensibility, in fact complete coma, the restoration to comparative 
health, and, return, if possible, with aggravated symptoms, are some 
striking features of these malignant intermittent or congestive 
fevers. I have seen, when at Whampoa below Canton, a sailor 
fall down on the deck within a few feet of me senseless and motion- 
less, as if apoplectic ; it was the first paroxysm of an intermittent 
fever, the second of which I prevented by the liberal and timely 
! administration of bark. On board of another vessel I was re- 
| quested to visit incidentally a man, the Stewart, supposed to be under 
the influence of poison; he was in a state of insensibility, comatose, 
! with occasional slight convulsions, and unable to swallow. Pie had 
j been in this state since the preceding evening. It was then ten 
i o'clock in the morning. External stimulants and an enemata of 
J turpentine had no effect. He died before noon. 

There are other cases, again, of these congestive and masked 



532 



CONGESTIVE FEVER. 



intermittents in which the reaction is slight and the remission hardly 
observable before another paroxysm of coma and its accompani- 
ments return, and carries off the patient. The dominant symptom 
is sometimes excessive coldness, as in the algid intermittent, some- 
times extreme and uninterrupted sweating, at others syncope, and 
again delirium. Occasionally, the part which most suffers is the 
pleura, or the lungs, and the pain of which recurs at regular inter- 
vals. Cases have been seen in which the periodical return of the 
paroxysm was marked by epilepsy or convulsions, or by acute and 
distracting headache. The type of the worst cases is double 
tertian — sometimes a mortal paroxysm with congestion would 
supervene on remittent fever. I have already mentioned the case 
of comatose tertian, when treating of intermittent fever, which oc- 
curred in my own practice in this city. Pinel relates the case of a 
comatose intermittent which was stopped by bark in an ounce dose, 
but in twelve days afterwards the disease showed itself in the form 
of a sweating fever, which was cured by the same remedy. 

Senac gives the following account of an epidemic remittent 
fever, w 7 hich, if reproduced in one of our medical journals under 
the name of another author, would be readily received as highly 
descriptive of congestive fever in Illinois, or in Mississippi : " The 
disease was for the most part marked with great oppression at the 
breast and about the precordia, delirium, and convulsions : it often- 
times assumed the appearance of true apoplexy, but more fre- 
quently that of lethargy ; at times the sick lay motionless, deprived 
of exercise and power of their senses; not unfrequently the paroxysms 
commence with severe headache, and the most excruciating pains 
in the joints. On the remission of the fever all those symptoms 
abated, and sometimes the sick appeared to be quite out of danger. 

" At other times, the disease assumed an aspect somewhat different; the febrile 
symptoms ran high, with an acute pain in the side ; the breast, as in peripneu- 
mony, was oppressed with a heaviness and a difficulty of breathing ; in some cases 
there was a continual and very distressing vomiting : in others suffocating sensa- 
tions, pains in the bowels, and such like symptoms raged with great violence 
during the whole course of the paroxysms : besides spasms and convulsive motions, 
many of the sick were subject to syncope : most of them to such extreme debility 
that they seemed ready to expire ; some of them indeed lay as if already dead ; 
during this great prostration of strength, the surface of the body was cold and of a 
marble appearance. 

" In all these cases the force of the pulse was various. At times the violence 
of the symptoms was so great as to break in on the regular course of the pa- 
roxysms, and render them obscure ; the pulse was then contracted and weak, as 
if there had been a deficiency of vital energy ; but at other times, and that most 
commonly, the febrile symptoms were high ; under these circumstances the pulse 
was strong and very frequent; in some instances, it was less elevated, and struck 
the fingers with less force : still it was sufficiently forcible to show of itself that 
the fever was very high." 

Of a double tertian the same author thus discourses : 
"In the following year a fever of the same kind became prevalent. It was a 
double tertian and continued sub-intrant. In this disease apoplectic and lethargic 
symptoms came on at the very commencement of the cold fit, and, such was their 
force, that they continued throughout the whole course of the paroxysm ; but as 



SENAC'S CASES OF FEVER. 



533 



I the paroxysm passed off, the sick revived as it were from the deplorable condi- 

I tion, and returned to the exercise of their senses and their intellect ; you would 

1 have sworn that they had suffered no injury. So great was the remission of the 

i fever and the intermission of the bad symptoms, that, provided the subjects were 

! young, they did not at first view appear to be sick : but when advanced in years, 

' their situation was much more dangerous, and unless art came opportunely to 
their relief, they soon fell victims to the disease." 

Cases of a fever which occurred three years afterwards are 
1 given by Senac, which I shall introduce to you in this place. I 
! wish so to familiarize you with the multiplied pictures and diver- 
! sified aspects of congestive fever as to make it impossible for you 
| to mistake its features w 7 hen once presented to you in the sick room. 

" A young woman was attacked by a remittent fever. In the third paroxysm 
j she became insensible ; her lungs were oppressed, her breathing became sterto- 
'\ rous, and in eight hours she died. The fate of my next patient was no less un- 
, fortunate and melancholy. He had been attacked by a double tertian fever, 
i During the third paroxysm he fell into a delirium which continued for three days, 
j During the day the fever was moderate, but it increased on the approach of night, 
and put a period to his existence. 

" Another person was attacked by a remitting fever, somewhat inclined to be- 
j come a continued one. On the fifth day he fell into a lethargy or coma, and an 
oppression of the breast coming on he expired. In a certain female subject, a 
disease of the same kind assumed a different appearance, and pursued a different 
course. The patient was attacked, for instance, by a genuine intermittent, but on 
the fourth or fifth paroxysm her mind became deranged, she continued in that 
j state without much fever for six days, and then recovered her senses ; but the 
fever again increasing, she was carried off by the next paroxysm. 

" A certain gentleman ill of a remittent fever, put himself under my care. He 
had daily a rigor and shivering : at length on the fifth day he fell into a lethargy 
which continued for twenty-four hours. By degrees, however, he recovered his 
' senses, and was of a sound and firm mind for one day, but a shivering and pa- 
roxysm occurring again, he died of a kind of asthmatic suffocation. No less un- 
expected was the fate of several other patients, who, after moderate paroxysms, 
became cold on the surface of the body and were seized with faintings ; their 
strength then failed entirely, and, after suffering great oppression, they expired." 

The reflections on the preceding cases, made by the author, are 
worthy of your remembrance, as conveying some important truths 
connected with the insidious beginning, violence of actual attack, 
and sudden and complete subsidence of all symptoms, as if there had 
been no previous disease. But I will let him speak for himself, as 
he does it so well and unpretendingly. 

" It appears from the foregoing circumstances, that these fevers attack more par- 
ticularly the brain, the seat of the intellect, but that they also do great violence 
and injury to the lungs. JNor are the prsecordia less affected, and even the heart 
j itself is a great sufferer. In a word, even the vital principle is attacked and 
j overwhelmed, as it were, by the febrile poison, and from hence are to be deduced 
\ the dangerous symptoms which the sick experience : these symptoms are so vio- 
j lent, particularly in persons advanced in years, that, unless the greatest attention 
! be paid to them in the commencement of the disease, they run on to a fatal issue. 
| Youthful persons more readily recover; yet many even of them are carried off 
either through a neglect of remedies, or by the force of the disease proving supe- 
I rior to the resources of art. 

j " It may be thought singular in these diseases, that sometimes from so slight a 
j beginning, the danger should become so urgent and threatening in the course of 
I a few days. But it is a problem no less difficult to solve, how a cause which so 
i disorders the brain, and so oppresses the lungs, can of its own accord give the sys- 

46 



534 



CONGESTIVE FEVER. 



lem a temporary respite, or cease for a time to act. Thus, after the third or fourth 
day the action of this cause is suspended, and for a day or more the patients seem 
free from disease. Other maladies do not pursue such a course; in them the af- 
fected parts recovered only by degrees ; and after they have recovered, or appear 
to have recovered in the space of a day or two, the life of the patient is seldom 
brought into danger again by a sudden return of the disease ; at least this is not 
generally the case, as it is in malignant intermittents. 

" Hence may be deduced a rule or conclusion of no small moment in acute dis- 
eases. It appears, for instance, that there may be great disorder in the functions 
of the body without either real inflammation or any fixed disease in the solid parts. 
Many patients are delirious, raving, and appear to labour under a peripneumony, 
others suffer the most excruciating pains, while others again have their stomach 
and bowels greatly disordered; they appear, indeed, to be in as much danger as if 
they were labouring under the greatest inflammation, under a wound, or some 
strong irritation about to extinguish the vital principle ; yet those parts which had 
experienced such deep and distressing affections, may in a short time be entirety 
relieved. Hence it appears that these terrible symptoms may arise from some 
wandering stimulus, which flies off and returns, or acts and lies dormant alter- 
nately ; and that they are sometimes more alarming in appearance than dangerous 
in reality." 

Cleghorn, {Observations on the Epidemical Fevers in Minorca,) 
after describing the symptoms of a paroxysm of a " true simple or 
double intermittent tertian," which does not differ from that com- 
monly met with here at home, goes on to remark : " as the fever ad- 
vances to its height, the coldness and shivering which usher in the 
paroxysms become less, or entirely imperceptible, in which case a 
cholera morbus, or acute pain in the back or limbs, often supply their 
place : frequently the shiverings are intermixed with flushings of 
heat. In the meantime the paroxysms themselves become longer, 
and bring on more formidable symptoms, such as headaches, raving, 
sopors, apoplectic fits, bleeding at the nose, cough, difficulty of 
breathing, palpitation of the heart, irregularity of the pulse, sickness 
and anxiety, pain about the upper (cardiac) orifice of ihe stomach, 
vomiting and purging ; heat, tension, pain, and pulsation in the ab- 
dominal viscera ; subsultus tendinum, and an infinite variety of other 
complaints, which do not entirely cease with the sweat that carries 
off the paroxysm ; so that the apyrexy is not only shortened, but 
rendered more obscure." 

Of the obscuration of the intervals by the paroxysms running into 
each other, and, in favourable cases, of their subsequent separa- 
tion, Cleghorn makes these remarks : " after this manner these pro- 
teiform distempers continue to vary their shape in every period, 
and to produce longer, more severe, or more frequent paroxysms, 
till they arrive at their height; about which time the fits and inter- 
vals are often so confused that they are scarcely to be distinguished ; 
nevertheless, if death be not speedily the consequence of this con- 
fusion, they commonly again put on a more simple or regular form, 
and after one or more slight paroxysms go away of their own 
accord." 

As contributing to the prognosis in these malignant or congestive 
intermittents, I may just repeat a remark by this author; — "that 
the danger in certain fevers is rather to be estimated from the 



LIND'S CASES OF FEVER. 



535 



symptoms of the paroxysms, than the length and serenity of the 
intermissions." He, afterwards, quotes from Torti to show that 
periodical and principally double or simple tertians become malig- 
nant, either when they degenerate into continual acute fevers, or 
when they still retain their intermissions, but are unaccompanied 
with one or other of the following symptoms, which commonly 
prove fatal in the second or third fit, after its appearing in the for- 
midable manner, which he (Torti) describes. 1. A vomiting or 
looseness like cholera morbus or dysentery. 2. A looseness which 
often resembles the hepatic flux, and sometimes a purging of black 
bile. 3. A cardialgia. 4. Cold sweats. 5. A syncope. 6. A con- 
stant coldness, neither succeeded by heat nor sweat. 7. A lethargic 
disposition, little different from an apoplexy. 

Lind in his work, which I regret is not more generally known 
and read, (An Essay on Diseases incidental to Europeans, in Hot 
Climates, SfC.,) gives two cases which will illustrate two of the 
varieties of intermittent, described by Torti, viz., the comatose, 
which Cleghorn says is common in Minorca, and the cardiac. 
The account of the treatment adopted in these cases, although 
somewhat in anticipation of this part of our subject, will not dis- 
tract attention from the chief point at this time. 

"1. A young gentleman was seized with a fit of an ague, and in half an hour 
became delirious, then comatose, at length speechless. Finding him in this .state, 
I ordered a blister to be immediately applied to his back, and a cordial julep with 
salt of hartshorn to be poured by degrees into his mouth. In two hours afterwards, 
upon recovering his senses so as to swallow with ease, I ordered him two ounces 
of tinctura sacra, and then as soon as the fever and sweat had abated, without 
waiting for the complete effect of the purge, half a drachm of the bark every four 
hours. He began the use of the bark three hours after he had taken the tinctura 
sacra; but before he had taken five drachms of it, he was seized with a second fit, 
and in like manner became delirious, comatose, and speechless. Sinapisms were 
applied to his feet, and other irritating applications used, until the fever was ter- 
minated by a plentiful sweat. Thus having twice narrowly escaped dying in the fit, 
a drachm of the bark was ordered to be taken punctually every hour. He soon took 
two ounces of it; which had so happy an effect, that the fever left him entirely, 
and he had not any subsequent dropsy, jaundice, headache, or great weakness, 
which either the continuance of the fever, or its repeated attacks, often brought 
upon others ; so that he was quickly restored to perfect health. 

"2. A lady, on the first attack of an intermitting fever, was seized with a vio- 
lent pain in the stomach. Every subsequent fit increased that pain, insomuch that 
at length it became intolerable, was attended with a violent delirium, and brought 
on a great difficulty of breathing, a hiccup, a ghastly countenance, and the symp- 
toms of approaching death. She found no benefit from emollient fomentations, 
from the external application of tinctura thebaica, or even from a blister. I 
ordered two ounces of the bark to be taken during one intermission of the fever. 
This effectually prevented its return, and did not in the least increase the pain in 
the stomach : on the contrary, it greatly contributed to the relief of the pain, by 
removing the fever, every fit of which had so exasperated its violence." 

Congestion coming on in the progress of a remittent fever and 
proving fatal, is a matter of frequent occurrence. The following is 
an example in point from Clark (Observations on the Diseases 
which prevail in Long Voyages to Hot Countries, fyc). The fever 
had been of twenty-two days' duration, and there was often several 



536 



CONGESTIVE FEVER. 



imperfect, and even more distinct remissions, so much so that the 
patient " was taken out of bed, conversed cheerfully, and seemed to be 
much better than usual. About eleven in the forenoon, in an 
instant, he found himself indisposed, and desired to be assisted to 
his hammock. He was seized with convulsions; his extremities 
became cold ; he lay speechless, and had all the appearance of 
approaching death. A spoonful of cordial volatile julep was 
poured into his mouth frequently, and bottles of warm water were 
applied to hrs feet. In three hours he returned to his senses. 
After this he became comatose, and his pulse was very small, 
quick, and irregular. A blister was applied betwixt his shoulders, 
the julep was given at times ; and he was supported with 
wine. His strength and spirits seemed now to be too much ex- 
hausted to expect anything from medicines. From this time the 
convulsive fits recurred frequently." Four days afterwards " he 
purged a considerable quantity of putrid bilious matter : he lay 
comatose, insensible, and died in the evening." 

On examination of the body the liver was sound, as were the 
intestines, " except the duodenum, which was corrupted for several 
inches, and contained some ounces of fetid matter, resembling a 
mixture of pus and bile. On examining the encephalon, the 
meninges, brain and cerebellum were of a natural appearance, 
and the cortical and medullary substances were sound, and bore 
handling better than in most subjects ; but in the left ventricle 
there was found about an ounce of bloody serum. The cavity of 
the thorax was not examined." No mention is made of the sto- 
mach. This case occurred at Canton. 

Another case, related by Dr. Clark, of a tertian, which by 
mismanagement was converted into a fever in which the remis- 
sions were imperfect, and there ensued severe quotidian exacerbations 
and congestion. On the morning of the 17th, the eighth day from 
the first attack, the patient (at Whampoa, near Canton), was 
seized with slight rigors ; and the paroxysm increased, with great 
heat and sickness at stomach. When first visited by Dr. Clark, 
at two in the afternoon, " his pulse beat 120 ; his skin was intensely 
hot and dry ; his tongue furred ; he was comatose, and had slight 
twitchings of the tendons. Half the prescription No. 1,* was given 
every hour. The stupor still increased, and his countenance 
became wild and staring. At seven he fell into a profuse sweat, 
which continued till twelve, but did not terminate the feverish 
paroxysm. A draught with twenty-five drops of the tincture of 
opium was prescribed ; and two ounces of a strong decoction of 
bark were directed to be given every hour in the night, and a 
dram of the powder, as soon as his stomach would bear it. 

" At ten, next morning, he had taken eight ounces of the decoc- 
tion and three drams of the powder. He was free from fever, but 
his headache remained. A dram of bark was ordered every hour 

* This consisted of a grain of tartar emetic, magnesia twelve grains, mixed. 



CLARK'S AND SHIELD'S CASES. 



537 



in port wine, which he continued regularly till night. By these 
means a return of the fever was prevented, which in all probability 
| would have proved fatal; but as, he was still very weak, half an 
] ounce of the bark was taken daily for some time." 

In the endemic fever of Bengal, sometimes without any previous 
indisposition, the patients fall down in a deliquium, during which 
the countenance is very pale and gloomy : as they begin to 
recover from the fit, they express the pain they suffer by 
applying the hand to the stomach and head, and after vomiting a 
considerable quantity of bile they soon return to their senses. 
Sometimes the attack is so sudden and attended with such excru- 
ciating pain at the stomach, that I was obliged, says Dr. Clark, 
from whom this description is taken, to give an opiate immediately. 
I Dr. Johnson states that in the bodies of those who died of this 
! fever, the liver was so engorged that it actually fell to pieces in 
J handling. The gall-bladder contained a small quantity of bile, in 
1 colour and consistence resembling tar, and the ductus communis 
I was so thickened in its coats and contracted in its diameter that a 
1 probe could scarcely be passed in it. Much incipient inflam- 
mation was visible in some parts of the small intestines, and the 
internal surface of the stomach exhibited similar appearances, 
No sign of actual inflammation was seen in the cranium* 

The endemic fever of Batavia is, also, highly congestive. Sur- 
geon Shields has contributed a good account of it in Dr. Johnson's 
work on the Diseases of Tropical Climates. The patient on the first 
attack frequently falls down and is insensible during the paroxysm, 
his body covered with cold clammy sweats, except at the pit of the 
stomach, which always feels hot to the palm of the hand; the 
pulse is small and quick. The length of the paroxysm varies from 
six to eighteen hours, and was generally succeeded by cold rigors,, 
very often low delirium, preparatory to the next stage or paroxysm 
of the fever. The intellectual functions now become impaired, the 
patient not being at all sensible of his situation or of any particular 
ailment. If the patient be asked how he is, he commonly 
answers, " Very well," and seems surprised at the question. 
This is a very dangerous symptom, few recovering in whom it 
appeared. A great proportion changed in a few days to a bright 
yellow, some to a leaden colour ; other cases terminated fatally, 
in a very rapid manner, too, without the slightest alteration in that 
respect. Generally, how r ever, the change of colour indicated great 
danger. Vomiting of black bilious stuff, as Mr. Shields expresses 
it, like grounds of coffee, frequently commenced early and con- 
] tinued a most distressing symptom, too often baffling all attempts 
j to relieve it. In some a purging of vitiated bile or matter, resem- 
I bling that which was vomited, occurred ; in a great many a torpor 
| prevailed throughout the intestinal canal ; rarely did any natural 
I faeces appear spontaneously. 

Hemorrhage from the mouth or nose seldom occurred; in two 

46* 



538 



CONGESTIVE FEVER. 



cases, which terminated fatally, the blood did not coagulate, but 
tinged the linen yellow. Aphtha? appeared in a few cases, and indi- 
cated great danger. Subsultus tendinum often attended both on 
the high and low delirium. The pulse could never be depended 
upon. Deafness was a very common and an unfavourable symp- 
tom. Two kinds of eruption appeared about the lips ; one such as 
we often see at the decline of common fevers ; the other consisted 
of small black or brown spots round the lips, and was likewise a 
dangerous and often a fatal symptom : at the same time with this 
eruption, the teeth, tongue and fauces generally become covered 
with a brown or black crust, and the breath was intolerably fetid. 
Locked jaw took place in two cases, but the patients were insensi- 
ble of it ; both died. 

Never, continues the narrator, was there a disease so deceitful 
as this fever; instances were frequently seen where every symptom 
was so favourable that the patient might have almost been pro- 
nounced out of danger, when, all at once, he would be seized with 
restlessness, black vomiting, delirium and convulsions, which in a 
few hours would hurry him out of existence. The brain appeared to 
be the organ chiefly affected at first ; the stomach and liver subse- 
quently. 

The resemblance between the disease now described and yellow 
fever is very close, and might easily induce a doubt of the accuracy 
of the opinion that this latter is not seen in the East. The case of 
John Hughes, a marine, is particularly worthy of commemoration, 
both as bearing on this point, and illustrative of the state of conges- 
tion, which, if it did not cause the fatality of the disease, im- 
pressed on it some peculiar features. After much suffering and 
many alarming symptoms,, this man was taken on the morning 
of the sixth day of the fever with violent black vomiting, which was 
checked at 1 p.m. by opium and ether, and a blister to the epi- 
gastrium. This state was accompanied by great restlessness ; a 
constant desire to get overboard ; skin cold and clammy ; brain and 
mental functions still much disordered ; craves for wine, which is 
given to him ; at 4 p.m. more collected ; begs to be sent to the 
hospital ; his request is complied with. At 5 p.m. he got up in 
good spirits, dressed himself; went into the boat unassisted ; when 
landed he insisted on carrying his own hammock and bed up to the 
hospital, which he actually did. He there drank a glass of port 
wine, and went to bed : at eight in the evening he was in a sound 
sleep, with a fine warm moisture diffused over his skin, and every 
symptom favourable. At five in the morning he was found dead in 
his bed, lying on his face, with nearly a gallon of red and yellow 
stuff, resembling blood and bile, under him, and which was still run- 
ning from his mouth. On shifting him to have him buried his whole 
body emitted the most intolerable effluvia. 

I have detected cadaverous emanations from the body even be- 
fore death in a person who was brought home senseless, and vomit- 



PATHOLOGY OF CONGESTIVE FEVER. 539 



ing occasionally mucus and bile, in consequence of a sun-stroke 
when engaged out of doors at his trade, — that of a carpenter. 

An observation, which merits recording here, was made respect- 
ing this Batavia or rather Edam fever, after the name of a small 
i island near Batavia and nine miles from the coast, at which were 
landed some of the crews of the English blockading squadron. It 
is, that no constitution was exempted from its assault. It seized 
] with equal or nearly equal violence on those who had been many 
I years in India, and on the most robust and plethoric, or newly-ar- 
rived European. Even the Dutch officers, and the Malays who 
had been drawn from different parts of Java, and who were prison- 
ers at Edam, fell victims as fast, or nearly so, as the English. 



LECTURE III. 

Congestive fever— Lesions of the organs,— How far observed in this fever — Dr. Bailly's 
observations and cases at Rome — Gastro-enteritis, arachnitis, and splenitis, common 
accompaniments of malignant or congestive fever — Importance of separating the 
symptoms, and their periodical recurrence, which depend on the nervous system, from 
those which are the product of inflammation in some organ — Great congestion and 
redness of the gastro-intestinal mucous membrane and gastro-enteritis may remain 
after the periodical fever is removed. — Congestion of an organ, the effect of nervous 
irritation, may react on the nervous system and complicate the symptoms. — Probability 
of the primary cause of the nervous irritation being a disorder and sometimes phlo- 
I gosis of the alimentary canal — Predominance of the nervous system in the produc- 
tion of the paroxysm of fever — Tendency to intermission in the functions of the 
nervous system — Periodicity depends on this system — Complications of the fever by 
inflammation of an organ — Double nature of intermittent fever — constituting a 
neurosthenia. — Antagonism of the nervous and vascular systems. 

After the pictures, exhibited in my last lecture, of congestive inter- 
mittent and remittent fevers in different parts of the world, you may be 
disposed to inquire whether these cannot be shown to depend on some 
organic lesion, or series of lesions of the organs. That we often see the 
associated phenomena of congestion in intermittent and remittent fe- 
brile disease and of anatomical lesion of an organ, is indubitable ; but 
their constant and necessary connexion is by no means so evident. 

I Reference has been made already to intermittent congestions of the 
brain, as in periodical apoplexy and epilepsy, and of the lungs in period- 
ical pneumonia and pleurisy which have left, we might suppose, no 
lesion behind them, so completely were the patients free from any 
symptom of such organic change, not only after the entire removal 

; of the disease but in the interval between the attacks. But, as we 

I shall soon see, where the fever sets in with violence, has but a short 
intermission, or a very imperfect remission, before the paroxysm 
recurs with renewed force, and great disorder of the digestive 
apparatus, there are at the same time engorged liver and in- 

| flammation of the small intestines and stomach, with which 



540 



CONGESTIVE FEVER. 



sometimes, not seldom indeed, that of the brain is associated. The 
distinction in these cases is this : that although there can be all the 
phenomena of intermission, and of intermission and congestion 
combined, dependent simply on disordered innervation and circula- 
tion, without any lesion of tissue or organ, yet is such lesion often 
connected with such phenomena, and contributes to increase their 
violence and complicate singularly their treatment. Permanent, or 
repeatedly renewed congestion of an organ, may greatly predis- 
pose to inflammation and hemorrhage, as inflammation in its turn 
will often invite afflux and bring on congestion. It is this blending 
of congestion with inflammation which makes both our diagnosis 
and our treatment of various forms of fever so difficult, and which 
has caused so much discrepancy of opinion among those who have 
written on the subject. In one case, the disturbances in the circu- 
lation, as by injection, and accumulation of fluid in an organ, or con- 
gestion, have ensued on prior derangements exclusively of the 
nervous system, and are removed by remedies, such as diffusible 
stimulants, tonics and narcotics, which act mainly on that system. 
In other circumstances, again, the vascular system, especially the 
capillary texture, has undergone great changes, besides that of mere 
capacity, and, which although still modified, cannot be removed by 
medicines addressed solely to the nervous system. By our bearing 
in mind this frequently double, or rather mixed nature of congestion 
in fever, we shall be more intent on analysing their phenomena, and 
more successful in modifying our practice according to the results 
of such analysis. We shall discover that stimulation and depletion, 
even by bloodletting, are not in contradiction to each other in the 
epidemic or endemic fever of the same season, nor even in the same 
individual in the same day, or in the same hour. But I somewhat 
anticipate. My present object is to introduce to your notice 
some cases of congestive or malignant intermittent fever, re- 
corded and commented on by M. Bailly [Traite Anatomico-P atho- 
logique des Fievres Inter •mittentes, Simples et Pernicieuses, &c. : 
Paris, 1825,) during his visit for this express purpose to Rome in 
the years 1820, 1821, and 1822. To the inquiring pathologist who 
ought to be something more than a mere morbid anatomist, the 
post mortem appearances of some of those who died from this 
fever will be interesting. These show, however, that which has 
been demonstrated at other times, that we cannot designate a 
fever by a distinctly ascertained anatomical character of the lesions 
which may occur in its course, although we often are called upon 
to note the organic changes which accompany and complicate it. 

Doctor Bailly gives an account, some of them in detail, of up- 
wards of sixty cases, of pernicious or malignant intermittent fever, 
which he classes in this manner : — 1. Those fevers, the predominant 
symptom of which was furnished by the head ; and are called 
comatose, delirious and convulsive. 2. Those whose chief symptom 
is abdominal disorder,— epigastralgic and gastric fevers, &c, rupture 



COMATOSE VARIETY. 



541 



and softening of the spleen, and putrilaginous softening of the liver. 
But we are not to suppose that dissection showed in the cases of 
either class a lesion solely of the organ chiefly affected. The very 
first observation recorded by M. Bailly of a case, which he desig- 
nates as a comatose, convulsive, pernicious intermittent fever, 
showed after death arachnitis, cephalitis, and g astro-enteritis. The 
patient who was thirty years of age and of a strong constitution 
j had laboured for some time under a tertian fever. He entered the 
I hospital on the 2d of July, 1822 ; on the 3d he had a slight paroxysm 
; of fever, after which he took two ounces of bark. On the 4th at 
i noon he was walking about in the ward, felt very well, and was 
■ joking with the other patients. All at once he was seized with a 
violent chill, which was succeeded by a high fever, during which 
I there was contraction and inflexion of the fore-arm on the arm and 
a profound coma; he died six hours from the accession of the fit. 

The second case was that of a man, twenty-eight years of age, and of a good 
constitution, who entered the hospital (San Spirito) on the 2d of August, 1822. 
j At half-past one in the day he was taken with a paroxysm of fever, which was 
ushered in with excessive cold, followed by heat and stupor. He laid on his back, 
! with his eyes half open, was roused when spoken to, and then fell again into a 
comatose state. The pulse was frequent and strong, the skin burning. In the 
night a copious sweat came on, manifested by large drops on the neck, head, and 
entire body. The intellect was restored, and in the morning he was able to 
answer questions respecting his health. He took several ounces of bark. 

On the 3d. the following day, the fever returned at noon, beginning with great 
cold, followed by heat, and a still more deep stupor; but he could always be roused, 
and when called he opened his eyes. The fore-arms were flexed on the arms so that 
they could not be extended. The lower jaw was strongly pressed against the 
upper one, and prevented his tongue from being seen. The skin had now but little 
sensibility ; decubitus on the back, — abdomen not affected by pressure. At half-past 
two a general sweat broke out; but not so abundantly as on the preceding day. 
In the evening there was a return of sensibility and intellect, with a cessation of 
the contractions of the arms, but his ideas were less clear. 

On the 4th of August, the third day of his entry, at half-past seven in the morn- 
ing, the pulse was frequent, and the patient was stupid and had the appearance of 
a drunken man. At eleven o'clock there was a return of the cold stage, which 
was less marked and shorter than the preceding one ; the fever was more violent, 
stupor more profound ; coma ; return of rigidity of the limbs ; subsultus tendinum; 
continued decubitus on the back; pulse strong and full. At half-past three o'clock 
sweat appeared, but less copiously than before. After the sweating stage the pa- 
tient could not answer any question, nor realize his position, — the contractions had 
ceased. 

On the 5th of August, at nine o'clock in the morning, there was a fresh pa- 
roxysm of fever, but the cold was shorter, and the hot stage more acute. Con- 
tractions of the forearms ensued, together with coma, laboured breathing, and rattle. 
Patient died at ten o'clock in the evening. 

The chief lesions of tissue noticed were arachnitis and slight g astro-enteritis. 
The liver was gorged with blood, and the spleen large and easily torn. 

The next case recorded b} r Dr. Bailly is of an icterous comatose 
fever of the pernicious intermittent kind. The patient, [a shoemaker 
by trade, sixty years of age] was taken sick on the 16th of August, 
with quotidian fever, and entered the hospital on the 24th. His 
whole body was of a deep lemon colour, — a change which he said 



542 



CONGESTIVE FEVER. 



took place during his last fit. The skin of the extremities was cold, 
and there was a feeling of inward heat; tongue red and dry ; pulse 
108, and threaded. He had so fully his faculties, that he smiled 
on the approach to his bed of Dr. Bailly and the other medical at- 
tendants who had spoken to him when he was first brought into the 
hospital. He made no complaints, appeared quite easy, and replied 
with readiness to every question asked. 

On the *^5th, in the morning, which was that of the eighth day of 
his disease, he was found with coma, immobile, and lying on his 
back ; insensibility of the limbs when pinched, but when pressure was 
made over the region of the stomach his whole body underwent a 
brisk movement ; persistent jaundice ; pulse not to be felt in the fore- 
arm, and at the crural artery beats 122. He swallowed some 
spoonfuls of bark during the paroxysm, which he afterwards 
vomited. Death took place at ten o'clock this morning. 

Together w r ith cephalitis and g astro-enteritis there was splenitis 
discovered in the autopsy. The lungs were sound, the cavities of 
the heart larger than natural, and in the right ventricle there was a 
clot formed entirely of albumen, of as decidedly a yellow colour 
as the skin and dura mater. The stomach was contracted on itself ; 
was of the colour of wine-lees throughout its entire extent; and 
although it was well washed there still adhered to the surface a thick 
mucus, like the indurated expectoration of patients affected with 
pulmonary catarrh. On the smaller and a part of the larger curva- 
ture, there was a kind of eruption, consisting of minute, round, and 
distinct elevations. The redness which abated at the pylorus was 
again as intense as ever in the duodenum, and this appearance 
was presented all the way through the small and large intestines. 
The gall-bladder was green externally, and was filled with a dark 
and thick bile, a few drops only of which could be squeezed out of 
the duct by strong pressure. 

The liver was of the ordinary consistence ; its colour of that of 
powdered yellow bark, the only instance of this kind seen by Dr. 
Bailly. The spleen, although of its usual size, was in so pulpy a 
condition that the pressure of the scalpel, in an attempt to cut it, 
caused its tissue to flow out like so much thickened jelly. 

The next case was one of a convulsive comatose fever of the 
pernicious intermittent kind, which terminated fatally in twenty-four 
hours after admission into the hospital. There was found after 
death arachnitis, gastritis, and a diffluent spleen. 

The sixth case, omitting the fifth, was of the same character 
with that just recorded. It was a fatal one, and exhibited after death 
cephalitis, putrilaginous softening o{ the liver, and enteritis. Each 
of the many inflamed spots of the intestines corresponded with 
bunches of worms, which were still alive. The lungs, spleen, and 
stomach, were healthy. Dr. Bailly introduces the history of a case 
of epigastralgic pernicious intermittent fever from Dr. Johnson's 
work, the subject of which exhibited after death putrilaginous soften- 
ing of the liver, and g astro-enteritis. 



GASTROENTERIC VARIETY. 



543 



A gastroenteric case of congestive remittent or pernicious fever 
is given by Dr. Bailly : — 

This man was sick ten days. The organic lesions were splenitis and gastro- 
enteritis. The patient was seized with chills, followed by heat and other 
febrile symptoms, including vomiting and diarrhoea, on the evening of the 28th of 
| September, 1822, after having been much heated and fatigued during the day 
j by riding on horseback. In the night he had a slight sweat succeeding these 
I symptoms. On the following day, a renewal of the disease in all its violence. A 
I purge was administered, after which the dejections were more numerous than 
| before. There was exacerbation in the evening, but without any chill preceding, 
i and the fever was kept up without any evident intermission until the 4th of 
| October — the day of his entrance into the hospital. At this time the patient had 
pains in the abdomen and loins, with fever, alvine evacuations, which were 
| bilious and frequent, and bilious vomiting. Thirst, dry and yellow tongue, 
j (Fifteen grains of ipecacuanha were prescribed, which produced copious vomit- 
. ing.) Evening: Fever continues; no chill; agitation increased; thirst; inter- 
i nal heat greater. (Barley water.) 

j October 5. Morning: Persistence of the fever, abdominal pains greater, dejec- 
tions constant ; thirst excessive, tongue dry, skin burning. (Enemata ; barley 
Water.) At 1 o'clock from noon, slight chills came on, and an increase of thirst 
and other symptoms. (Snow water for drink; eight scarifying cups to be ap- 

! plied; cataplasms to the abdomen; barley water and milk.) Half past 8 in the 
evening, pulse very full ; same symptoms as before. (Venesection to the extent 
of a pound.) Slight sweat in the course of the night. 

6. Morning: Vomiting less urgent ; dark alvine discharges ; extremities cold ; 
pains of the abdomen persistent. (A scruple of sulphate of quinine; gummy 
drinks and a general bath prescribed.) Temperature of the bath not mentioned. 
Afternoon : 2 o'clock ; chills ; exacerbation of fever ; at a quarter after five the 
extremities are cold and livid ; pulse small. (Four blisters to the limbs ; has vo- 
mited all the sulphate.) 

7. Morning: Extremities cold; slight pain of the head; abdomen painful under 
pressure; alvine dejections copious; pulse 85 and full. (A scruple of quinine 
was prescribed, but part of it lost by vomiting.) Afternoon : Chills about 12 
o'clock. At 2, the extremities still cold, livid, abdominal pains and vomiting 
and dejections still frequent. (Two additional blisters to the thighs, mustard 
pediluvium, and sulphate of quinine in the remission.) The patient vomited 
several doses of the quinine. 

8. Morning : Skin hotter ; intestinal discharges continue, vomiting less fre- 
quent; tongue rough like a shark's skin; abdomen painful under pressure; a 
jaundice colour of the whole body. Evening : Chills ; extremities like ice ; hic- 
cup frequent; aggravation of the other symptoms. (Scarifying cups; snow 
water; sulphate of quinine.) Death at 8 o'clock in the evening. This man 
retained his intellect throughout, except the last few hours, during which time 
there were no other nervous symptoms than drowsiness, which always precedes 
the last agony.^ 

In addition to the organic lesions of gastro-enteritis and splenitis already men- 
tioned, there was injection of the lumbar porlion of the medulla spinalis, and some 
fluid in the ventricles. The valves of the stomach as well as those of the intes- 
tines were thickened and engorged. The rectum was more inflamed than the 
colon. The small intestines were contracted, and rested on the spinal column. 
The next case was one of the entero-cephalic variety. The appearances on 
I dissection were cephalitis, arachnitis, gastro-enteritis and splenitis. Duration 
! of the case (in the hospital) five days. The exacerbation of the fever took place 
I every evening. On the fourth day, in the morning, there was beginning feeble- 
; ness of intellect ; decubitus in the back ; slowness of reply ; irregular movements in 
j the muscles of the mouth when he was asked to show his tongue ; pulse slow ; ab- 
i domen flattened ; pains of the stomach. In the evening there was profound stu- 
j por, the eyes half open, pupils contracted, jaws firmly closed. The forearms 
were flexed on the arms at right angles and contracted ; sensibility throughout; 



544 



CONGESTIVE FEVER. 



sweat abundant, and flowing in large drops from all parts of the skin. (Bark three 
ounces.) At half-past eight in the evening the contraction had ceased, but the 
stupidity remained : it was necessary to open his mouth for him in order to make 
him swallow the bark. (Sinapism to the feet.) 

On the next day, in the morning, the patient was in the same state ; no contrac- 
tion ; he took all the bark which had been prescribed the evening before, and without 
having rejected any of it. (Two ounces of the bark were administered by enema.) 
At eleven o'clock there was a paroxysm of fever which come on gradually, 
and was accompanied with the following symptoms. Forearms rigid and flexed 
at an acute angle on the arm ; jaws closed ; lethargy; respiration slow and sonorous ; 
pulse hard ; tongue withdrawn to the back part of the mouth ; insensibility ; ab- 
domen flattened, — when it is pressed on the patient utters a cry of distress. (A 
pound of blood was taken from the foot.) Relaxation of the limbs, which cease to be 
contracted; epigastrium always painful. (Blisters to the arm and the nucha.) 
Rattle, — died at six o'clock in the afternoon. 

Following this case, there is one of epigastralgic pernicious 
intermittent of the double tertian type, which displayed, by autopsy, 
g astro- enteritis and biliary cystitis. The next is a delirious con- 
gestive or pernicious fever, the organic lesions in which w r ere 
arachnitis, g astro- enteritis, and splenitis. To this succeeds a case 
of gastro-cephalic fever, which was accompanied by arachnitis, 
gastritis, and splenitis. 

Among the varieties of congestive or malignant intermittents, 
the algid has been already mentioned. Excessive coldness of the 
surface and feeble circulation of the cutaneous capillaries, do, we 
know, occasionally follow various diseases of the nervous system 
alone. In other cases, pathologists are also aware that the most 
intense inflammation is at times accompanied with extreme cold- 
ness, or at least a painful sensation of coldness by the patient. Hence 
it is an interesting point to be able to show what connexion this 
symptom has with visceral congestion and inflammation. Dr. 
Bailly has recorded four cases in succession of this intermittent 
algid fever; and certainly the enumeration of inflamed tissues and 
organs in the bodies of those persons who perished under its 
attack is most formidable. In the first we read after — Autopsy : Arach- 
nitis, enteritis, splenitis, gastritis, pericarditis. The subject of it, 
aged eighteen years, and of a good constitution, was brought into 
the hospital on the evening of the 29th of July and died on the 30th 
in the evening. During the night after his admission he com- 
plained continually of acute pains in the belly ; his body was of an 
icy coldness : he took an ounce of bark. 

On the 30th, in the morning, at eight o'clock, his legs, thighs, 
arms, and cheeks, were of an icy coldness ; the abdomen, chest, fore- 
head, were a little below the standard temperature ; pulse not to be felt 
at the arms, carotids, temples, or over the heart; and only indis- 
tinctly at the crural arteries, which beat 100 in a minute. The patient 
was unceasingly restless and uttering complaints ; more commonly 
he laid on the left side, with the thighs flexed on the abdomen. 
When questioned he understood what was said, but could not fix 
his attention to answer correctly; although answer he did, with 
great readiness, but without entering into any details. He died 



ALGID VARIETY. 



545 



at half-past nine. The small intestines exhibited a deep red or 
violet, and the large, down to the rectum, inclusive, was of a lively 
red colour. The stomach was dotted with blood, which was 
I easily removed : its mucous coat was thickened. The liver was 
' healthy, the spleen large and hard, and of a wine-lees colour. There 
( were slight adhesions of the pleura to the right lung, and of the 
|! whole surface of the heart to the pericardium. The arachnoid was 
] injected, and there was engorgement of the vessels distributed over 
the convolutions of the brain, and of those which make up the plexus 
| choroides. 

The next case of algid fever was of a man sixty years of age, of 
j a thin habit of body, but healthy up to the date of attack, 19th of 
' August, 1822. He had a paroxysm of the common kind, which 
j went off in a sweat. On the 19th he was brought to the hospital, 
and had a return of the fit, in which he complained much of 
inward heat. Expression anxious; the features were in a manner 
flattened on the bones of the face ; the complexion was natural ; look 
heavy. (Half an ounce of bark in the wane of the fit.) 

Evening: decline of the fit, skin moistened with a viscous and cold sweat; 
pulse small and frequent ; agitation general ; pain at the epigastrium ; tongue red, 
but moist; no thirst. (Half an ounce of bark.) Throughout the night the skin 
was moist. Patient vomited the bark. 

On the 20th of August, in the morning, there was remission of fever, the pain 
had disappeared, and the countenance was tranquil. About noon a fresh paroxysm 
came on, and although a great heat succeeded the chill, the extremities remained 
cold, and the skin was covered with livid spots. On the 21st, general calm, 
;| but the extremities still cold ; pulse small and frequent. Towards noon there was 
a return of fever, preceded by chill ; exacerbation of the preceding symptoms. 
1 The patient does not feel the coldness; he is in a measure benumbed and torpid. 
(Bark : an ounce to be taken through the night.) 

22d. Skin less cold ; pulse small and frequent, a viscous sweat over the whole 
body ; look heavy. (Two ounces of bark.) At ten o'clock return of the paroxysm ; 
pulse not to be felt at the arm, beats 140 at the crural artery. An icy coldness of the 
j extremities ; abdomen flattened, even concave, its parietes applied as it were to the 
spine; pain of the stomach, agitation, anguish; the patient, who has never lost his un- 
derstanding, is in a stateof torpor, which barely allows of his answering any question, 
j The complexion is natural. (Twelve leeches applied to the epigastrium ; blisters 
to the arms; bark, three ounces in powder to betaken during the night. He has 
1 vomited the bark.) 

23d. A well marked remission. Towards nine o'clock return of the cold, which 
is like that of marble ; pulse imperceptible, artery beats 144 at the thigh. Pain of 
the stomach more intense; anxiety, great torment; eyes sunken. The cold, which 
hitherto had been confined to the extremities, extended to the shoulders and the 
pelvis. The head was cool, the thorax and abdomen not of their natural temperature, 
thighs icy like the legs. Evening: Same state; he did not feel the cold of 
his legs, but was aware that when touched by another the skin of the latter was 
warmer than his. Pain of the stomach incessant. Lies on the back. (Scari- 
fying cups to the epigastrium, sinapisms to the feet, blisters to the thighs, and 
| nine grains of the sulphate of quinine, which he did not vomit.) During the night 
I augmentation of all the symptoms. Death at three o'clock in the morning, up to 
! which date he remained sensible. Eight hours after death the body was rigid and 
the limbs hard, as if they were frozen; abdomen sunk in. The temperature of 
the air was above 77° F. 

Autopsy. — The appearances of some of the organs were so indicative of in- 
tense inflammation as to justify a somewhat precise notice. The arachnoid was 
injected, and there was engorgement of the vessels on the convolutions, and se- 

47 



546 



CONGESTIVE FEVER. 



rosity between the laminse of the arachnoid ; the cerebrum and cerebellum were 
healthy. The heart and lungs were sound. The stomach, contracted on itself, 
showed on its inner surface intense redness, increasing towards the pylorus ; the 
rugae of the mucous membrane very distinct. The small intestines externally like 
the stomach, of a gray colour, were on their internal surface of a more decided 
redness than the abdominal muscles, which were of the common colour. The 
large intestines were of a still deeper hue, and so intensely inflamed that the 
colour of the muscles even would not serve as a point of comparison,— an appear- 
ance which was noticed on to the sigmoid flexure and the rectum. The liver was 
healthy; the spleen in a middle state between diffluence and health. 

The inflammation in this case was only comparable to that of 
the algid one previously described. 

A third case of algid fever with singultus, also terminated fatally, 
exhibiting after death gastritis and arachnitis. The subject of it was 
forty years of age, and of a good constitution ; he had a fit of the fever 
in the city, and was brought into the hospital on the 7th of July, in 
the morning. The hands at this time were colder than those of a 
corpse; pulse 108, small and firm; singultus regular in its returns, 
fourteen times every minute; decubitus on the back; heaviness, 
from which he is easily roused ; replies correctly ; complains of a 
pain in the region of the liver. In the evening, decline of the parox- 
ysm and disappearance of the hiccup. 

At eight in the morning, a complete return of consciousness 
and of natural expression : the hands are always icy, and the coldness 
extends to the middle of the forearm. The patient does not feel 
that they are cold ; but if they are put on his abdomen, he is very 
sensible of their coldness : he speaks as if he were in health. At 
nine o'clock, his countenance assumes a silly expression ; he 
answers slowly, and as if by compulsion. He is inclined to stupor ; 
he lies on his side, the lower limbs flexed on the abdomen: the fit 
has come on, and the coldness reaches to the trunk ; the respiration 
is short, and at times convulsive, with a slight shock, giving rise to 
the idea of hiccup. He died at three o'clock in the afternoon, 
with his eyes open. He took bark during the apyrexia. 

Autopsy. — General injection of the arachnoid, which is thick, red, 
and its surfaces united as it were by a bloody false membrane : 
the vessels on the cerebrum are gorged ; the stomach is much 
inflamed in its pyloric portion : the rest of the digestive canal is in a 
natural state. 

A fourth case of algid fever, of a malignant or pernicious nature, 
is recorded by Dr. Bailly. The patient was 35 years old, of a 
weak constitution, and lymphatic: he had been chilled by going 
into one of the grottoes "of Monte Testuccio, and in vain tried to 
remove this feeling by drinking seven glasses of wine. To this 
succeeded great weakness, which was the predominant symptom 
from this time until his entrance into the hospital, six days after- 
wards. July 11th. He had a feeling of general pain, but so few 
symptoms of fever that his physician could not make up his mind 
as to the fact. He took a vomit and purge, and continued at his 
trade — making maccaroni. When he came into the hospital he 
had somewhat the expression of a drunken man. His pulse was 



ARACHNITIS. 



547 



I frequent and weak ; the temperature of his thighs, legs, hands and 
arms was cold ; the tongue was moist and not red. He could 

[ give an account of his previous condition, but with so much labour 
that he was fain to refer the physician to his companion for further 

j details. In the afternoon he was twice unwell. 

Evening: pulse scarcely perceptible, great distress, cold extremi- 

! ties; the left hand colder than the right, and of a livid colour. 

j Temperature of the abdomen and chest almost natural ; face pale ; 

I is delirious and restless. (Prescription : Decoction of bark, eight 

j ounces; extract of bark and theriaca, each a drachm ; laudanum 

I and anodyne liquor each twenty drops ; camphorated emulsion ; 

I blisters to the thighs.) 

July 12th. At half-past one from midnight, there was a general 

j and copious but cold sweat. In the morning, at the hour of visit- 

| ing, the debility was the same as before ; pulse imperceptible in the 

! arms, which are cold, as are the thighs ; the abdomen is rather 
warmer, but below the natural standard ; pulse at the head is 114 ; 

j vesicated surface is pale, and no serum under the cuticle, which is 
only raised. He has his senses ; but displays a tendency to stupor. 

1 He makes no complaint of pain ; the abdomen not painful under 
pressure ; only complains of extreme weakness. (Blisters to the 
arms ; two drachms of bark in wine.) 

A little later, recurrence of the symptoms ; alternation of delirium 
and stupor ; intense general coldness. Death at half-past five m 
the afternoon. Half an hour after death the body was warmer 

I than before that event. 

Dissection showed arachnitis, g astro-enteritis, and splenitis. The 
stomach was much inflamed ; the intestines were so in spots ; the 
spleen was in a pulpy state; liver healthy; old adhesion of the 
right lung. On opening the cranium a good deal of sanguinolent 
serum escaped from the occipital foramen : the arachnoid was 
injected through its minutest ramifications, but more on the left 
than the right side. The vessels on the surface of the convolutions 
were much engorged ; mare evidently on the left side. The gray 
matter of the brain rather paler than otherwise ; choroid plexus 
pale ; serum between the convolutions ; the consistence of the 
brain was soft. 

There is one point in the morbid appearances so constantly 
recorded by Dr.Bailly on which a remark suggests itself. I refer to the 
arachnitis, which he describes as present in nearly all the cases, and of 
an intensity too which is almost without parallel. Some experienced 
pathologists express strong doubts about the arachnoid ever under- 
going such a notable change by phlogosis as the other serous 
I membranes, or to the extent of its exhibiting vessels; and think that 
I an opaline appearance, and thickening of the arachnoid, are as strong 
evidences of its inflammatory state as we can expect commonly 
to find. Be this as it may, we seldom meet with so remarkable 
a lesion of this membrane as was almost uniformly noticed and 
recorded by Dr. Bailly, in nearly all the w T orst cases of malignant 
• or congestive intermittent fever. 



548 



CONGESTIVE FEVER. 



On looking over the histories of thirty-six cases of malignant 
intermittent recorded by Dr. Bailly which ended fatally, I find the 
proportion of structural alterations of tissue or organ to be as fol- 
lows : Arachnitis, 25 ; Gastro-enteritis, 19 ; Splenitis, 18 ; Rupture 
of the spleen, 3; Diffluent spleen, 2; Cepalitis, 13; Gastritis, 7; 
Enteritis, 7 ; Alterations of the liver, 5, — of which 1 was by 
inflammation, 2 by congestion, and 2 by putrilaginous softening ; 
Pneumonitis, 3; Pericarditis, 3; Peritonitis, 2; Parotiditis, 1; Oeso- 
phagitis, 1 ; Cystitis (biliary), 1. The tissue which suffered most 
frequently was the arachnoid, although not to the extent described 
by Dr. Bailly; since, as I have already mentioned, the symptoms 
of arachnitis are seldom if ever so distinctly declared as we should 
be led to infer from these cases. M. Louis thinks that arachnitis 
proper is a rare affection, and that the inflammation so commonly 
represented to be such is that of the subjacent cellular tissue. Com- 
monly as the inflammation of the arachnoid is supposed to bring with 
it that of the brain, or at any rate functional derangements of this 
organ, there were cases in the preceding list in which the patient pre- 
served his consciousness and intellect to the last, although dissec- 
tion showed after death very evident arachnitis. If we were to 
add the 7 cases of gastritis to the 19 of gastro-enteritis, we should 
have 26 cases of gastric inflammation out of the entire number of 
36 ; and in the same manner, if we add the 7 cases of enteritis to 
the 19 of gastro-enteritis, we find 26 cases of intestinal inflamma- 
tion. The number of cases in which there was a union of arach- 
nitis or cephalitis with gastritis, or with gastro-enteritis, was 25 ; 
and of arachnitis or cephalitis with enteritis, 7. We might say 
that there was inflammation of the brain, or of its arachnoid mem- 
brane, conjoined with some part of the digestive canal, and chiefly 
of the stomach in 30 out of the 36 cases. There was inflamma- 
tion in some part of the contents of the abdomen in every one 
of the whole number. 

1 wish to press these statistical results on your attention, and 
w r ould ask you to bear them in mind when you read and hear of 
liver disease and hepatic derangement and congestion, as a great 
cause, indeed the chief cause, of congestive and autumnal remittent 
fevers. You will see from the above returns how poorly figures 
bear out this hypothesis. I was myself once, when a student, and 
for a while afterwards, under this hepatic delusion; so far indeed 
as to induce me to choose the liver and its diseases for the subject 
of my Inaugural Dissertation for the degree of Doctor of Medicine 
in the University of Pennsylvania. I remember very well being 
complimented by Dr. Chapman, then my teacher, and ever since 
my honoured friend, for the arrangement of the matter, and 
the style of the essay; but he added, as I also remember — " You 
are all wrong." I will repeat the expression, gentlemen, to you, 
and say you are all wrong, if you allow yourselves to believe 
that the organic origin and support, either of the acute or 



CONGESTION OF THE SPLEEN. 



549 



sub-acute febrile diseases, which you will meet with in the summer 
' and autumnal months, is in the liver. You will be doubly wrong 
if, on the strength of this erroneous pathology, you prescribe calo- 
mel, in every kind of dose, and at all hours and seasons, to remove 
I this imaginary hepatic disorder. Even if the premises were real, 
and you had to deal with undoubted hepatitis and congested liver, 
J the therapeutical inference, that mercury is the remedy which 
j should be given early, freely and long, is a sad mistake. 

If we look for the organ which showed most proofs of conges- 
I tion we find it to be the spleen, which was affected either in this 
I manner or with congestion and inflammation conjoined, or its tissue 
broken up, in 23 cases out of the 36 already referred to. Some 
J writers are disposed to attribute the occurrence and repetition of 
j intermittent fever either to congested spleen or to congested liver 
; but particularly to the former; and, in confirmation of their belief, they 
I cite the frequency of the cases of enlarged and indurated spleen in 
persons residing in low and marshy districts of country, who 
I are at the same time victims to periodical fever. But in this 
instance, and it is not a solitary one in medical inquiries and specu- 
! lations, the effect is mistaken for the cause, and congestion, which 
is really the effect and product of nervous irritation acting on the 
circulation, is spoken of often as the cause of this abnormal state 
of the nervous system. The afflux of fluids and their retention for 
a while, constituting an orgasm of the part, is a consequence of 
nervous excitement, and what is more, it can follow from this cause 
| alone. But if in place of being simply a physiological phenomenon 
of temporary duration, as in the normal congestion of the organs of 
generation in coitu, of the mucous membrane of the stomach in di- 
gestion, and of the liver during this same period, and of the brain 
under the influence of strong yet pleasing emotion, it should become 
pathological and fixed — then, like any new body or growth, the con- 
gested tissue is a foreign and unpleasant stimulus to the nervous 
system on which it reacts, and which it sometimes continues to 
disturb and irritate in various ways. Congestion of the spleen and 
chronic splenitis may, therefore, be admitted to be occasional 
causes of intermittent fever and to contribute to its obstinacy ; but of 
the relatively small account which is to be made of them, and of the 
| circumstances under which this fever is produced and maintained, 
j the following facts will satisfy us. First : intermittent fever, both 
I simple and congestive, will make its attacks and recur without any 
evidence of prior disease of the spleen. Secondly : in cases of 
! enormously tumid abdomen owing to enlarged spleen, there is 
i often no periodical fever present, or if it occur we can temporarily 
j remove it by bark or quinine, and yet the enlargement remains. 
| It may be thought that the congestion of the cerebral vessels and 
of the mucous membrane of the stomach and intestine, so con- 
spicuous, in most of the cases recorded by Dr. Baiily, especially in 
the algid variety of malignant or congestive intermittent, ought to 
be enumerated among the causes of the fever. You remember the 

47* 



550 



CONGESTIVE FEVER. 



intense redness, as if of complete injection by colouring matter, of 
the greater part of the lining membrane of the whole intestinal 
canal, in some of the cases, the details of which I laid before you from 
Dr. Bailly's book: and it is but natural that you should attach no 
little importance to this phenomenon, in reasoning on the causation 
of the fever. But here, as in the circumstance of congested spleen, 
we should err if we looked upon this gastro-intestinal congestion to be 
the cause of the paroxysm of intermittent or remittent fever, as the 
case may be. And here I will not pretend to draw the line between 
what was actually congestion and what inflammation, in the morbid 
state of the digestive canal, reported by the author under the names 
of gastritis, gastro-enteritis, and enteritis. It is most probable that 
congestion preceded but did not last long without inflammation, 
and that this latter was exacerbated at each paroxysm by the 
renewed and increased congestion. For the purposes of the present 
argument, and still better of practical instruction, it will suffice if I 
speak of the gastro-intestinal surface as in a state either of congestion 
or of inflammation, or of both combined. The point of adjudication 
is, whether the malignant or pernicious intermittent, the fever which 
we call congestive, has necessarily or even commonly for its cause 
inflammation in some part or other of the gastro-enteric membrane. 
In the affirmative it will be argued that this part is continuedly ex- 
posed to irritation ; that it is liable to be daily, even hourly affected, 
both by agents directly applied to it, including the common ingesta 
and various indigestible and crude matters, and by impressions and 
organic movements transmitted to it from the skin and lungs. The 
habits and exposures of those who are the greatest sufferers from 
intermittent fever, dispose in a remarkable manner to gastro-intes- 
tinal irritation, which is speedily followed by congestion and inflam- 
mation — a result seemingly evidenced by the appearance of the 
tongue, loss of appetite, nausea, and epigastric or abdominal tender- 
ness. Finally, that which the symptoms render so probable is 
positively demonstrated in the appearances of the mucous mem- 
brane of the stomach and intestines after death, as already described. 
To this it may be replied; that the fact of gastro-enteric disease, 
and that of considerable intensity too, is not denied. The point at 
issue, for the present, is the actual relation which such inflammation or 
congestion has to the series of phenomena characteristic of inter- 
mittent, fever. Is it a necessary cause, a causa sine qua non, or is 
it a conjunction, an aggravating circumstance, only? Can we 
not have intermittent fever without inflammation — or if the two 
happen to be associated together, can we not remove the type of 
the fever, and yet the inflammation persist ? 

A very rapid glance at the part which the nervous system per- 
forms, and performs exclusively, either alone or by its direction, in 
periodical disease, will convince us that the type of the fever, its 
characteristics — chills, diffused and high heat and sweat — will be 
manifested in consequence of simple irritation of this system. Inter- 
mission belongs to the nervous system, both in its several parts, and 



PERIODICITY OF NERVOUS FUNCTIONS. 551 



in its entireness in health, and its aberrations or exaltations in dis- 
ease. We are most sensible of this in the nervous system of animal 
"life, or of the cerebro-spinal axis and its nerves, including those of 
sense and motion — as in the alternation of waking and sleeping. 
But the fact is evident also in the functions of organic life, all of 
which, and notably those of digestion, have their period of alternate 
rest and of activity, — and of diminished and of augmented excitement. 

j It is a strong proof of the necessity of periodicity to the nervous 

I system, that although its irritants are in some cases ever present, 
its perturbations in consequence of the irritation are intermittent, 

j and recur only after regular intervals. Epilepsy, coma, catalepsy, 
hysteria, though occasionally depending on fixed organic cause or 
lesion unsusceptible of change, are often not the less regularly 
periodical. A spicula of bone in the cranium, an imperfectly 

| divided nerve, a neuroma, or ganglion pressing on a nerve, have 

I each of them been abiding causes of epilepsy of a periodical 
character, in which there was as entire interval of absence from any 
nervous or muscular disturbance as if the exciting cause had been 

!! entirely removed. 

Another peculiarity in the action of the nervous system is, that 
when once irritated there is a tendency to the recurrence of all the 

' phenomena of the primary irritation, although the first exciting 
cause had not been present, nor its application subsequently renewed. 
Thus, the irritation caused by the introduction of a catheter has 
been followed by a febrile paroxysm, consisting of chill, reaction, 
and sweat, which returned after a stated interval, and finally re- 
quired bark for its removal. Similar phenomena have been pro- 
duced by daily immersion in a cold bath, and have recurred for 
some days at the same hour even after desisting from the use of 
the bath. 

As we have seen that periodical diseases, including intermittent 
fevers, are often the product of simple irritation of the nervous sys- 
tem, it remains for us to ascertain whether gastro-enteritis, or 
gastro-intestinal congestion, is that kind of irritant which excites 
the nervous system in such a manner as inevitably to give rise to 
intermittent fever. The reply to this is soon made ; — for we all 
know that, notwithstanding the various and complicated secondary 
disturbances in the nervous, arterial, and muscular systems, and in 
the organic apparatus of secretion, absorption, and calorification 
caused by inflammation of the gastro-enteric mucous membrane, 
periodical fever is not by any means either an inevitable or a com- 
mon consequence of such phlegmasia. The same remark applies 
to simple irritation of the stomach, as in gastralgia, which, 
j although often periodical itself, does not provoke a regular inter- 
i mittent fever. In regular phlegmasia of the digestive mucous 
membrane there is commonly a daily remission, but not of that 
| distinct character so noticeable in the case of periodical fever. 

In bringing now the two parts of the argument to bear collec- 
tively on the case of congestive intermittent, we see — 1, that 



j 



552 



CONGESTIVE FEVER. 



the nervous system is the seat and apparatus for display of that 
collection of symptoms constituting periodicity ; and secondly, that 
this system requires an exciter, in order that it shall develop this 
property of periodicity. The seat of the phenomena is a unit — re- 
garding as such the two divisions of the nervous system — but the 
exciters and the organs of excitement are very diversified. On 
analysis we shall find, however, that the greater, and by far the 
greater number of origins of that excitement of the nervous system, 
"which is marked by changes in nutritive life — as of augmented 
circulation, respiration, and secretion, is in the digestive mucous 
surface and its appendages. This is itself excited at regular inter- 
vals : it is made obedient to the hours of eating and drinking, and 
to the modification of exercise and repose, and the erect and supine 
position, which are periodical in their recurrence, and which impress 
the entire nervous system in a periodical manner. Were we to 
suppose that the extended mucous membrane of the alimentary canal 
had only a common excitability at the period just preceding disease, 
yet, still, it is so often exposed to uncommon exciters, by the quality or 
excess of the ingesta both fluid and solid, that it is constantly prone 
to become the seat of sanguineous afflux and congestion, which may 
sometimes exist alone, sometimes run on to inflammation, some- 
times find relief by excessive secretion. From these proceed the phe- 
nomena of congestive fever if the nervous system in general has been 
correspondingly impressed by prior irritation and subsequent sedation ; 
or of cholera, diarrhoea, and dysentery, if the circle of irritation be 
restricted to the nervous system of organic life. 

In the congestion or inflammation of the stomach, or of the 
intestines and the organs subsidiary to digestion — the spleen, liver, 
and pancreas — so long as it lasts we have a continued source of 
irritation to the nervous system. If, coincidenily with this stage of 
the digestive organs there be a condition of the nervous system 
induced by a particular atmospherical constitution, we have the phe- 
nomena of intermittent fever ; but no longer of the simple fever. 
With the depression of the nervous system in the chill, there is a 
depression of the diseased organs which modifies this part of the 
paroxysm, and with the reaction of the nervous system, which in 
health would show itself by a little increased warmth, is the reac- 
tion of morbid and suffering organs, by which the circulation is 
disordered, the heart irritated, and its balance with the capillaries 
disturbed. A new train of symptoms is now produced, which are 
neither the simple exponents of an excited nervous system, nor of 
the inflammation or congestion of particular organs, but a com- 
pound of both. Giannini designated the state of reaction in the hot 
stage of fever by the term neurosthenia : it is not neuralgia merely, 
nor phlogosis merely, but a mixed state of irritation of the nervous 
and vascular systems. But without insisting on refinements in this 
matter it will be sufficient, and it is also necessary, that we should 
bear in mind the union of nervous irritation with inflammation 
of an organ ; a double nature to be broken up by a double attack, 



NEUROSTHENIA. 



553 



or by an attack with double means, — one directed against the nerv- 
ous system, another against the inflamed organ. We may remove 
the periodicity, the element of nervous irritation, by bark and its 
congeners, but the phlogosis will remain ; we may carry off the 
I phlogosis, but the nervous irritation and its periodical display in 
the febrile paroxysm will persist, and even be manifested some- 
times with more violence than before. There would seem to be an 
I antagonism between the sanguiferous and the nervous systems, — so 
I that the more you deplete and weaken the former, the more you 
j exaggerate and complicate the phenomena of the latter; so, on the 
! other hand, the more you excite the nervous system the more 
I tranquil and composed and less irritated is the sanguiferous. This 
fact is strongly exemplified in hysteria and hysterical epilepsy, 
l and in certain stages of fever, in which free blood-letting aggravates 
all the nervous symptoms, and induces a fearful complication of them, 
j Abundant nutriment and active exercise, which favour hsematosis 
or sanguification, abates and finally removes this complex series of 
I nervous disturbances in epilepsy and hysteria. 

Both in periodical and in continued fevers of an aggravated 
I character we must expect this display of double forces, and must 
shape our measures accordingly. There would, according to the 
principle now inculcated, be no harm in bleeding and giving quinine 
and opium at the same time. By the former remedy we should 
relieve the oppressed organ, and prevent the alteration of the 
tissues which converts congestion into inflammation ; by the two last 
! we moderate the nervous irritation, and prevent the excessive in- 
nervation by which vascular reaction and the danger from aug- 
mented congestion becomes much more serious and alarming. 



LECTURE IV. 

Pathology of congestive fever continued — Congestion caused by nervous irritation 
may disappear with removal of its cause — Predisposition of particular organs to be 
affected — Inflammation aggravated by every febrile exacerbation — Nervous sys- 
tem excited or oppressed by its appropriate agenis, irrespective of vascular changes 
— Conjunction of fever with inflammation of an organ — the two diseases independent 
of each other — Continually to have the nervous system in our mind when studying 
fever — Diagnosis of pernicious intermittent or congestive fever — Appearance of the 
patient — Great and sudden changes in — Uncertainty of symptoms furnished by the 
tongue, and discharges from the stomach and bowels — Urine — Pulse — Secretions — 
Prognosis — Death during the hot stage of reaction, and commonly in the latter part of 
the day or in the night — Greatest violence on even days — Unfavourable signs — Re- 
covery after seemingly fatal signs — Termination of the fever at fixed periods — Aver- 
age duration of a case of fever. 

I In beginning this lecture I will just advert to wdiatyou will perhaps, ere 

I this, have thought to be a manifest contradiction among authors on the 

j nature of the organic complications which constitute congestive or per- 

I nicious intermittent and remittent fevers. Some of those whom I quoted 

j tell us how astonishing it is, that, after the violence of attack of par- 

| ticular organs in successive paroxysms of the fever, no evidence 

' remains of a change in the relation or size of any of the parts 



554 



CONGESTIVE FEVER. 



of the organs to each other ; as in the case, for instance, of apo- 
plexy, or coma and lethargy, coming on with a paroxysm of the. fever, 
and going off with it, and yet leaving no mark behind. Others, 
and as we might suppose, more careful observers, such as Dr. Bailly, 
show almost uniformly the remains of some organic lesion; gastro- 
enteritis, or splenitis, or arachnitis, and often two or three of these 
combined. But the contradiction in this case is more apparent 
than real. The series of symptoms of the fever now under consi- 
deration maybe produced by simple irritation of the nervous system, 
which, in its reaction, gives rise to injection of tissues and accumu- 
lation and congestion of blood in the organs, and consequent de- 
rangement of function similar to those organic changes and the 
sympathetic disturbances and effects caused by inflammation. 
The brain, lungs, stomach, intestines, liver, and skin, are all in a 
state of temporary excitement by irradiation on their vessels, as the 
heart is from similarly augmented nervous power, in the reaction 
of the paroxysm of intermittent fever. All these organs may, after 
a longer or shorter time, part with the excess of blood which they had, 
and lose at the same time their morbid susceptibility; in fine, be re- 
stored to their pristine state; thus illustrating the remark of Senac 
already quoted : " that there may be great disorder in the functions of 
the body without either real inflammation or any fixed disease in the 
solid parts." But whilst this explains the general reaction and febrile 
exacerbation, it is still inexplicable to many how an organ should 
have its functions so completely suspended, and in a manner which 
at other times is commonly if not necessarily fatal. A know- 
ledge of the difference in predisposition of particular organs aids us 
in a solution of the difficulty. One organ is oppressed by a rernoraof 
blood in it which is hardly inconvenient to another. One per- 
son has the vessels of the brain habitually turgid, and the organ re- 
duced to a state of indirect debility by severe and protracted intel- 
lectual labour. A change in the mode of innervation, such as 
occurs in the paroxysm of fever, is sufficient in this case to augment 
the vascular fulness in the meninges of the brain to an extent that 
brings on apoplexy. But as there is no rupture of vessel, nor lesion 
of the cerebral substance, the apoplectic seizure lasts no longer 
than the cause which produced it ; and as this last was but a con- 
gestion induced by the excitement of the nervous system, and tem- 
porary, its removal is followed by that of the apoplexy. A re- 
storation of the vessels of the brain to their usual state and of the 
nervous system to its medium excitement, suffices for the cure. But 
as no attack of this kind is quite harmless, the brain is less able to 
bear the same amount of pressure, and the vessels the same disten- 
tion as before, and a renewal of the apoplectic paroxysm may 
be attended with much more serious consequences than before. 
The prevention of this event is brought about by acting on the 
nervous system, and indisposing it for the irritation and reaction 
which gave rise to the congestion. Bark or quinine, by prevent- 
ing the return of the paroxysm, and altering the mode of in- 



NERVOUS COMA. 



555 



nervation, has been said to cure the apoplexy ; but, in fact, it has 
| cured the morbid state of the nervous system, one of the symptoms 
I of which was this apoplexy. A similar explanation is applicable to 
coma and lethargy, and arachnitis even, as well as other anomalous 
i and alarming symptoms in congestive fever. Here, however, an 
j important question occurs, whether the trouble in the nervous sys- 
tem itself, sufficiently great to simulate these maladies, may not be 
! produced by impressions made on it, irrespective of phlogosis of its 
1 membranes and substance. Drowsiness and sleep are the conse- 
j quence often, if not always, of transmitted impression from the nervous 
! system of organic or nutritive life to the brain. But let the impression 
j transcend the normal or physiological degree, as after excessive reple- 
' tion, and the drowsiness will pass into a state of almost apoplectic 
stupor. The same result is obtained by the transmitted irritation of 
certain narcotics. In other cases, again, indigestible matters of a 
cold nature, such as some of the cucurbitacece and brassica, produce 
a directly prostrating and really poisonous effect on the gastro-intes- 
j tinal nervous expansion, which is transmitted to the brain and is 
followed by insensibility, coldness of the surface, small and almost 
extinct pulse. A pathological state of the digestive system and of 
its auxiliary organs is every now and then met with, in which the 
sensations are of an obscure yet unpleasant nature, just short of 
pain; and the abdominal nervous system, the larger part of that 
of organic life, transmits this irritation to the brain, in which it gives 
rise to coma. The patient is easily roused, seems to notice what 
is said, but lapses immediately into an apathy and stupor, as if op- 
pressed by the deleterious influences just described. The nervous 
system is at this time in a perverted state ; one, in fact, of irritation. 
The remedy should be such as to act directly on it, either by a 
sedative influence, like that of opium, or by a modifying one com- 
pounded of sedation and tone, as that of quinine. In another form 
of the disease, there is no doubt that coma is caused by the pres- 
sure of congested, or the excessive irritation of inflamed meninges, 
and is associated with different states of the vascular system from that 
of the first or simply nervous kind. To be able to determine the 
difference between the two is a matter of difficulty. There is, 
indeed, much more difficulty in symptomatology than we should 
suppose in reading the formal and dogmatical description of dis- 
eases, based upon their differential diagnosis. The nervous sys- 
tem is capable of being excited and depressed, and of having its 
functions variously modified and perverted, by simple irritation or 
sedation acting on its own tissue, and in parts remote from that on 
which the morbid action seems to be concentrated. When treat- 
ing of neuralgia I had occasion to state that the violent pains re- 
ferred to a particular nerve or spot in a limb, were at times really 
caused by a morbid change in some part of the central mass ; and 
we know full well, that the violent temporary disturbances in the 
cerebral functions, as in epilepsy and hysteria, are often caused by 
irritation of a remote nerve. Modifications and perturbations of the 



556 



CONGESTIVE FEVER. 



nervous system, including those which disturb, by depraving or abo- 
lishing the intellect and sentiments in fever, are, at times, undoubt- 
edly the consequence of irritation of a phlogosed membrane ; the 
gastro-enteric at a distance from, or the arachnoid in proximity to, 
the brain. There is nothing, therefore, specific or peculiar in in- 
flammation which disturbs the nervous centres and their functional 
operations ; nor is it essentially different, as an exciter, from those 
other material causes which act through the atmosphere, and by 
means of various ingesta and medicinal stimuli and sedatives. 

It will be impossible for you either to obtain just notions of the 
circle of the phenomena which make up congestive fever, or to 
devise a proper curative course for its removal, unless you bear 
steadily in mind the paramount part which the nervous system per- 
forms. By its instrumentality the succession of paroxysm and in- 
terval, constituting the disease one of intermission, are gone through: 
by the excitement of this system the various congestions are pro- 
duced, and through it they are often removed. Frequently, all the 
alarming symptoms derived from the circulation, respiration, state 
of the animal heat, and from the secretions, are but effects of dis- 
turbance of the nervous system, a removal of which causes all the 
others to cease, and to cease all at once too, as if by enchantment. In- 
flammation may supervene to aggravate the fever, and confuse in a 
measure its type : but whether the former is cured or remains, the 
latter will still exhibit its characteristics. You may have a case of 
phthisis and of intermittent fever, as M. Bailly relates his having 
seen at Rome — you will cure the fever by bark or quinine, but the 
organic disease of the lungs persists as before. You may have to 
treat a case of dysentery, conjoined with intermittent fever, like that 
which Torti records; and like him, you may cure the latter by the 
customary febrifuge, and yet the dysentery will end fatally, and you 
will find ulcerations along the whole course of the colon. 

Without a constant observation of the nervous system you cannot 
appreciate the true character of many of the symptoms — the sudden 
and early stupor, the disinclination and at times the complete inability 
to move. The feeling of sinking and the entire prostration of mus- 
cular power are not, as in most acute diseases, in any proportion to 
the extent and violence of the inflammation, or to the impediment to 
nutrition. A man who has been sick but a few days, and who still 
retains his fulness and muscular development, will find himself 
unable to rise from his bed or to stand up — such has been the strong 
and deteriorating impression made on the nervous system ; an impres- 
sion which lasts, too, sometimes after the periodicity of the fever is 
broken, and the morbid cause, whatever it may be, no longer acts. 
His appearance may indicate health, his pulse be full and slow, and 
yet for several days after the last paroxysm he lies, per force, on his 
back, powerless and nearly motionless. I have often been struck 
with the fact, and pointed it out at the time to some of my young 
friends who were present, of the torpor of faculties, the stupidity 
and bewilderment of patients who had suffered for a while from only 



INFLAMMATION WITH PERIODICITY. 



557 



the common intermittent fever. No real or presumed state of an 
organ in which inflammation or vascular change of any kind has 
taken place, is adequate to account for this state of things. It is 
seen in and through the intervention of the nervous system alone, 
and on it should our attention be fixed, in order that we may obtain 
a correct diagnosis of its disorders in the case. 

But, on the other hand, let us not exaggerate the importance of 
the manifestations of the nervous system, to the exclusion of a notice 
of the phenomena of the associated inflammation of some important 
organ. The periodicity of the attacks of fever, and the interval of 
comparative exemption from pain, heat, and other evidences of inflam- 
mation, have induced some to denytheexistenceof this latter state,and 
to allege that a periodical phlegmasia is impossible. I have already 
anticipated this objection, by showing that, no matter what may be 
the kind of irritant which calls the nervous system into morbid action, 
no matter whether it be ever present or applied at stated intervals, 
the disorder of this system and the accompanying phenomena will 
not be the less periodical. Inflammation does not prevent or destroy 
periodicity ; nor does periodicity preclude inflammation, although 
it will often greatly modify it. In the last stage, or that of reaction 
in fever, the already inflamed and weakened vessels being now 
more injected than before will be less able to pass on their con- 
tained blood, and hence congestion ; the minute capillaries are ex- 
cited more, and hence new formations, or an increase of former ones, 
which is in fact an increase of the inflammation. So that, although 
we are ever so fully persuaded of the fact of an organ being inflamed 
in periodical congestive fever, we must not on this account be the less 
anxious to break the periodicity, and to prevent the return of a parox- 
ysm which, in the manner just described, must necessarily increase the 
danger of the inflammation, both by an increase of the morbid sympa- 
thies and by the formation of new products. Here, again, there is 
danger of erroneous and hasty inference, by supposing that the 
remedies which prevent the recurrence of the paroxysm through 
their action on the nervous system are also remedies for the cure of 
inflammation. Quinine and opium will, by their operation in the 
first mentioned case, mitigate inflammation ; but the organic lesion 
remains, and is not to be removed in this way. This remark is 
applicable not only to the coexistence of gastro-enteritis, but also of 
arachnitis, cephalitis, splenitis, and less rarely of peritonitis, pleurisy, 
and pericarditis, with intermittent or remittent fever. In a case of 
urgency, we should give quinine to prevent the recurrence of the 
febrile paroxysm which aggravates the inflammation, whilst at the 
same time we should bleed freely to subdue this latter and save the 
affected part from disorganization. Herein is a difference between 
the congestion which is brought on by the paroxysm and disappears 
with it, and which may be cured by the same remedy used to pre- 
vent the latter, and the inflammation which is mitigated but not 
cured by the prevention of the paroxysm. 

These general, and, I hope, useful views of the relations which the 

48 



558 



CONGESTIVE FEVER. 



nervous and the vascular systems bear to each other, and the 
manner in which the former is impressed by, and, in its turn, 
influences the congested and inflamed organs in fever, having 
been stated, I shall next proceed to make some remarks on the 
diag?iosis and the value of symptoms in the disease. It will be 
readily believed that, as congestion is associated with such 
various forms of fever, the symptoms must vary greatly in a cor- 
responding manner. In this part of our subject, an explanation 
of seeming anomalies must still be found in the extent to which the 
nervous system has been impressed, rather than in the degree or dura- 
tion of phlogosis and congestion of the organs and functional tissues. 
We are safe in saying at the outset — 1, that nearly all the country 
fevers, especially those met with during the summer and autum- 
nal months, are ushered in with chill and other evidences of a 
morbid state of the nervous system, which are followed by reaction, 
making up the febrile paroxysm ; 2, that this morbid excitement is 
followed by a remission or partial subsidence, and sometimes an entire 
absence of the fever; 3, that after a longer or shorter period there 
is a recurrence or exacerbation of the disease, manifested by nearly 
similar symptoms and in the same order with those of the first 
attack, the recurrence commonly being of a double tertian type ; 4, 
that the obscurity of the remission, or want of perfect intermission, is 
generally owing to the perturbation of the nervous system, caused 
by a congested or inflamed organ ; 5, that the danger will be in 
proportion to the violence of the symptoms during the paroxysm, 
rather than to the appearance during the interval ; 6, that the parox- 
ysmal attack in intermittent and remittent congestive fever com- 
monly takes place in the morning or early part of the day. 

There is hardly any question so easy of solution as the recognition 
of most intermittent fevers, — but, adds Dr. Bailly, who makes this 
remark, there is nothing more difficult than to make out a case in 
which the intermission is marked by symptoms indicating an acute 
inflammation which had existed anteriorly to the fever, and may- 
still persist with it. Believing that we have still to deal with the 
same disease, inflammation, we are apt to regard each exacerbation 
as the signal for a repetition of the active antiphlogistic measures 
employed at the beginning. 

The hour at which the paroxysm first comes on, and that of sub- 
sequent exacerbations, will influence us in forming our opinion as 
to the probable kind and origin of the fever. On this point we 
look in vain for any information in the occasional essays on con- 
gestive fever in our journals. If the attack is in the morning, 
accompanied as it may be by delirium and convulsions, or stupor 
and coma, we shall refer it to congestive fever of a periodical type, 
and attach less danger to it than we would to a similar febrile 
attack in the evening, as in this latter case we may fear the symp- 
toms depend more on fixed inflammation. But we are not to infer 
that a paroxysm in the morning implies safety — since, in the great 
majority of the cases recorded by Dr. Bailly, this was the time in 



DIAGNOSIS. 



559 



which it came on. The worst cases of what is commonly called 
bilious remittent fever, but which were in fact congestive, that I 
j ever saw, had their paroxysm ushered in very early in the morning, 
sometimes before daylight. When, therefore, you are aroused from 
j your beds by an urgent call to visit a case of remittent fever at this 
I hour, or are told by the nurse or friends in attendance that your 
! patient has had a violent fit at this time, you must shape your mea- 
j sures so as to prevent its return the next morning. Certain it is 
J you will not be allowed the same time for treatment under such 
j circumstances as you might be if the exacerbation were to occur at 
! least at noon, or in the afternoon. 

j The general expression of the patient in congestive fever less 
j distinctively indicates the internal trouble than in continued or 
common inflammatory remittent fever. A certain fulness of fea- 
' ture and limb in the former contrasts with the contracted and pinched 
! features in the latter ; or when we compare common gastroente- 
ritis with that associated with congestive intermittent fever. The 
; sudden transition from the agonies almost of death to ease and 
comparative health, is another characteristic of the fever in ques- 
j tion : but this transition, although pleasurable to the patient, must 
not mislead the physician, and make him blind to the probability of 
a renewal, on the next or the second day, of the worst symptoms, 
and, perhaps, a fatal termination. If, however, a person ignorant of 
the type of the fever be unreasonably confident of entire* restoration 
to health on account of the absence of every unpleasant symptom 
I during the interval, he will, very likely, exaggerate beyond all mea- 
sure the danger during the paroxysm. What, in fact, can be more 
alarming to a novice, and disquieting to even the most experi- 
enced observer, than to find a patient prostrate on his back, head 
resting wherever it is placed, but usually thrown back, and the 
pillow under the neck ; the mouth half open, the eyes either shut or 
' wide open, and utterly deprived of expression ; whilst there is entire 
immobility of every feature and limb, together with insensibility of 
I both the trunk and limbs to the common means of irritation, by 
| pinching or pricking the skin. But even at this moment, when the 
patient seems to be moribund, we notice a different expression of 
! the face, which is relatively full, from that which is designated as 
the Hippocratic and precedes death in other diseases. 

In passing rapidly under review the chief symptoms, I shall 
begin with the tongue, and here we find confirmation of the nega- 
tive position advanced by Dr. Stokes in his lecture in the first part' 
of this volume, viz., that the appearance of the tongue often fails as 
a measure of the state of the stomach and digestive organs. Thus, — 
! Dr. Bailly very frankly admits that if he had not examined the 
i bodies of those who died of pernicious fevers, and if he had, as here- 
! tofore, admitted it to be a maxim founded on observation — thatin- 
1 flammation of the stomach is always revealed by redness of the 
tongue, he would not have hesitated to assert, simply from an 
inspection of this organ, that there was no gastro-enteritis in inter- 



5C0 



CONGESTIVE FEVER. 



mittent fever. But as, in fact, he never, or hardly ever made a dis- 
section without finding inflammation, he was compelled to alter his 
opinion, after having during the lifetime of the patient very seldom 
seen the tongue red. Not only was it not red but it was often 
without the yellowish or whitish coat, which, as a matter of course, 
we expect to find in febrile cases, — whether we are believers in the 
gastro-enteric or in the hepatic pathology of the disease. So little 
importance do the Roman physicians attach to the appearance of 
the tongue in their fevers, that they seldom ask to look at it. J mention 
this fact as illustrative of the want of connexion often between the 
tongue and the stomach ; but not as worthy of your imitation. Our 
own writers commonly speak of the tongue at the beginning of the 
fever being of a red colour at its tip and sides, and of a coated white 
or yellow, and sometimes a brownish hue at its middle. 

An equal difficulty exists in forming our diagnosis from the pulse 
in congestive fever — it being sometimes natural, sometimes full 
and frequent, or slow and full, and at other times small, frequent, 
and intermitting. Until the appearance of the cholera in an 
epidemic form amongst us, it was reserved for a stage of congestive 
intermittent or remittent fever, including an occasional case, of 
yellow fever, to exhibit the singular phenomenon of a patient being 
entirely pulseless, even up to the large arteries, and yet to preserve 
his intellect and sometimes power of locomotion. Contrasted with 
this picture of a particular stage or variety of the fever is that of 
another, in which there is an alteration of sensibility, thought 
and motion, and yet a full, strong, and regular pulse, and a 
skin bathed with sweat. This last feature will enable us to 
distinguish the disease from apoplexy, in which the skin is neither 
hot nor moist, and the expression of the face is rather of a person 
sleeping than of a patient in the paroxysm of fever. Again, if the 
physician find his patient with a skin, particularly that of the ex- 
tremities, of an icy coldness, and yet a retention of intellect and 
motive power, he may be pretty sure that he has a case of algid 
congestive fever before him. The inflammation of a viscus which 
would produce similar coldness just before death, would also give 
rise to an extreme feebleness and approaching extinction of the other 
functions at the same time. In reference to the state of the skin on 
the inception of congestive fever, you will find that, whilst the surface 
generally is cold, dry, and somewhat shrunk, the upper part of the 
chest, and the neck and forehead are in a state of moisture. 

We know that the invasion of most fevers is marked by gastro- 
intestinal distress, nausea and vomiting, with often heat and some- 
times pain. The accession of congestive fever is frequently an- 
nounced in a like manner ; but there is little proportion between the 
discharges from the alimentary canal and the intensity of the 
disease. The irritation of the stomach and duodenum may be ex- 
tended to the liver, and bile be mixed with the ingesta and mucus 
thrown up by vomiting, or show itself in the stools. Commonly, 
however, there is a suspension of the natural secretions and excre- 



DIAGNOSIS. 



561 



tions, and often of late years in their stead a serous fluid is largely 
poured into the intestinal canal, and as largely discharged per 
anum. The quantity of fluid thus secreted is not an evidence of 
excessive congestion, or accumulation of blood by inflammation in the 
vessels of the intestines ; for, often, these phenomena are very evident, 
although the secretion be small and almost arrested, and in cases 
in which it has been largely poured out, the mucous surface and 
glands were neither inflamed nor surcharged with blood. The 
symptoms of inordinate serous discharge is to be regarded as proof 
of high irritation of the abdominal nervous system by which the 
function of the secretors is strongly excited : — and in the remedies 
for allaying this irritation we shall discover the means for arrest- 
ing the excessive discharge. Its periodical return or exacerbation 
will be farther proof of the correctness of the nervous pathology 
now advocated. 

Of the secretions which have most influenced the diagnosis in 
periodical fever, simple or congestive, the urine is chiefly entitled to 
notice. A reddish-brick dust sediment has long been alleged to be 
a characteristic symptom. Sydenham among others speaks of " the 
colour of the urine, which in intermittent is mostly of a deep red 
(but not so red as in the jaundice), and likewise lets fall a lateritious 
sediment." Now, although, we cannot receive this symptom in 
the unlimited sense in which it has been announced, still it is an im- 
portant aid in forming a judgment, when we find diseases of a 
mixed or complicated nature, sometimes without, but more com- 
monly attended with fever, and recurring or being aggravated at 
irregular intervals. A similar sediment is an index to an inflam- 
matory affection, or at least to its partial remission, although in this 
case there is a cloudy or thickened portion of urine, which affects 
its transparency, rather than a dust-like precipitation at the bottom 
of the vessel, which mixes uniformly with the urine, as in intermit- 
tent fevers. The urine in these last affections is quite limpid ; 
the sediment when at rest forms a very thin layer at the bottom 
of the vessel, whilst in most inflammatory affections the sedi- 
ment, even when the urine is at rest, has some lines of thick- 
ness ; and it is partially blended with the upper portions of 
urine, whose specific gravity seems to be the same with it. It 
resembles, in fine, clay diffused in water, and not a colour- 
ing matter heavier than the urine, such as we find to be the case 
in intermittent fevers. In conclusion, we must not suppose that 
every disease in which this brick-dust sediment is manifested in the 
urine is a periodical fever ; but, when we find ourselves, in a country 
during a season in which these diseases are liable to occur, we 
may reasonally suspect that the one before us, even though masked, 
is of this character. 

The symptoms depending on the modifications of sensibility in 
congestive fever are not uniform in occurrence or intensity, and in 
this respect differ from those furnished in simple inflammatory 
remittent fever. Pain of the stomach and in the abdominal region, 

48* 



562 



CONGESTIVE FEVER. 



generally, either original or by pressure, is not complained of by the 
majority of patients in the disease now under consideration : — and 
yet it is worthy of notice, that in some of the cases recorded by 
Dr. Bailly, the person who was apparently insensible to all stimuli, 
exhibited great distress when decided pressure was made on the 
abdomen. I have frequently myself noticed the same thing in 
persons who were lying comatose in congestive fever. Some of 
our own writers, in describing the symptoms of congestive fever in 
the southern states, mention the extreme tenderness of the abdomen 
on pressure below the umbilicus. It has been said, and I believe truly, 
that, although the nervous system is impressed in warm countries, 
in a manner and with a display of aggravated symptoms of great 
excitement not generally seen in northern regions, yet it does not 
manifest in the former case, so uniformly as it does in the latter, 
the minute degrees of sensibility by its sympathising with an in- 
flamed organ. Of this fact examples are furnished in the cases of 
Dr. Bailly; for, notwithstanding that arachnitis was so frequent, 
there was not by any means corresponding frequency of pain 
referrible to such a cause, nor disturbance of cerebral function 
which would naturally be thought to ensue. The changes of tissue in 
inflammation are modifications of secretion and nutrition, which may 
or may not be announced by pain or irritation of the nervous system ; 
and hence an important inference, that the absence of pain is no 
proof of the absence of inflammation ; and conversely, that a very 
slight change in organic life may be responded to by the nervous 
system in such a way as to give rise to violent pain. 

The pains in congestive fever are of two kinds : 1, those in the 
period of chill or concentration ; 2, those of theperiod of expansion or 
heat. A knowledge of these, as also of the pains during the apyrexia, 
is only to be acquired by experience, and not by induction from 
pathological anatomy. Their recurrence after certain intervals, 
and union with fever, in which we cannot see the usual indices of 
inflammation, may induce suspicion of the nature of the disease. 
Headache, the most frequent of the lesions of sensibility in periodi- 
cal and congestive fever is most severe in the hot stage or that of 
reaction in the majority of cases ; but sometimes the cold stage is the 
one of greatest suffering in this respect. 

As regards the prognosis in congestive fever, you may readily 
infer that it is by no means easy. It is a common impression that, 
as the congestion is greatest during the cold stage, the danger is 
greatest ; and that death, when it occurs, is most apt to take place at 
this time. But this is an error. Cleghorn says ; " I have seen some 
expire in what may be called the first stage of the paroxysm ; the skin 
being chilled and wet with cold sweats ; their pulse small and irregu- 
lar, and their senses entire to the very last : but the greatest numbers 
are hurried off in the height of the hot fit, stupified, senseless ; the 
breathing short and laborious, and the skin covered with a burn- 
ing fever sweat." And in another page he says ; the most formida- 
ble paroxysm which 1 have seen, broke out into a burning heat at 



PROGNOSIS. 



563 



the beginning without any previous cold. And in looking over 
Bailly's numerous cases, I find that death in nearly all came on 
during the period of reaction, imperfect reaction indeed, but still in 
the stage succeeding to that of chill and first invasion. The ac- 
cession was, as I have already stated, generally in the morning, 
and the death occurred in theafternoon and night. Of thirty-one mortal 
cases, death took place in twenty between 2 p.m. and 10 p.m. ; five 
in the morning ; two at noon ; four between midnight and 3 a.m. 
In the post meridian twelve hours, or rather from about 2 p.m. to 
2 a.m., the deaths were twenty-three out of the thirty-one. In the 
cases which terminated fatally in the morning, the accession was 
on the preceding evening. In most of them the skin was warm 
and often bathed with sweat, sometimes of a viscous kind in the last 
and fatal stage. 

It has been already stated that the danger in congestive 
fever is to be estimated more by the violence of the symptoms in 
the paroxysm, than by the length and tranquillity of the intermis- 
sion. " Those fevers are most to be dreaded," says Cleghorn, " whose 
violence is greatest on the even days (counting the day of acces- 
sion as one day) ; and if the paroxysm stops on the third, fifth, or 
seventh day, but continues on the fourth, sixth, or eight day, we 
must be upon our guard, lest a sudden stand should succeed this 
treacherous intermission." I refer with more freedom to the his- 
tory of tertian fevers and the reflections of authors on them, as I 
am convinced that the congestive fever in our southern and western 
states is but a masked or malignant tertian, commonly of a double 
kind, in which there is a daily paroxysm, — but with a sameness 
in the symptoms and hour of recurrence between the paroxysms of 
alternate days only. The shortness and obscurity of the interval, or 
rather the prolongation of the period of the paroxysm, make the 
fever approach to the continued type, or at any rate lead the phy- 
sician to suppose that he has a case of remittent fever before him, 
while the symptoms of congestion or inflammation of the organs, 
such as the brain, the stomach and spleen, give origin to different 
names for the fever, and cause entire forgetfulness of its original 

The following description by Cleghorn is a better guide for prog- 
nosis of a fatal result than can be found in more recent works. 
" But the utmost danger is to be apprehended, if a few drops of 
blood fall from the nose ; if black matter like grounds of coffee is 
discharged upwards or downwards ; if the urine is of a dark hue, 
or strong offensive smell ; if the whole skin is tinged with a deep 
yellow, or anywhere discoloured with livid spots, or suffusion ; if 
a cadaverous smell is perceptible about the patient's bed ; if in the time 
of the fit he continues cold and chilly, without being able to recover 
heat ; or if he become extremely hot, speechless and stupid, has 
frequent sighs, groans or hiccups, and lies constantly on his back, 
with a ghastly countenance, his eyes half shut, his mouth open, his 



564 



CONGESTIVE FEVER. 



belly swelled to an enormous size, with an obstinate costiveness, or 
an involuntary discharge of the excrements : which formidable 
symptoms, as they seldom appear before the third revolution of the 
disease, so they frequently come on, both in double and simple in- 
termittents, during the fourth, fifth, or sixth period, even where the 
smallest danger was not foreseen : but at whatever time the greater 
part of them occur, they afford a melancholy prognostic ; for not- 
withstanding they sometimes go entirely off with the paroxysm, and 
the patient seems to be left in a fair way of recovery, yet most 
commonly they return in the next period with double violence, and 
terminate in sudden death." On the same authority as the fore- 
going, we may say, that the stage of the paroxysm which the 
patient usually got over with most difficulty, will most probably in 
the end prove fatal. The following observation, confirmatory of 
some preceding remarks which I made on diagnosis, is worthy of 
being remembered : " that as in all acute diseases, so particularly 
in those fraudulent deceitful fevers, the presages either of death or 
recovery are not always certain and infallible ; it frequently hap- 
pening that those who have laid in the paroxysm for hours together, 
with few or no sign of life, have at length recovered as it were 
from the jaws of death, and asked for some uncommon sort of food, 
to the great surprise of everybody about them ; on the other hand 
the fit, anticipating sometimes, brings on death before the time it 
was indicated." 

In proof of the uncertainty of prognosis in congestive fever, I may 
cite the case of a man which I attended in 1823, when the various 
forms of periodical fever were so common in the suburbs of this 
city, and in the adjoining country. My patient had a subintrant 
tertian, one paroxysm coming on in the evening, another in the follow- 
ing morning ; the latter the more violent of the two : he had towards 
the conclusion of the fever, involuntary discharge of feces and urine, 
and exhausting or not critical sweats ; but yet he recovered to the 
possession of entire health, and is still living. 

We shall attach different significations to a symptom according 
to our knowledge or belief of its organic origin. Thus, coma of a 
simply nervous character, or somnolency, is a state which may be 
compared to that of sleep in excess, and will not inspire the same 
alarm as that other kind which depends on organic lesion, — inflam- 
mation, for example, of the cerebral substance, or a congestion 
which presses this organ on all points, or, finally, a serous or sangui- 
neous effusion. In the first or nervous coma the patient can be 
awakened if we call and shake or pinch him; thus evincing con- 
sciousness, although he relapses very soon into his former state. 
In the other kind of coma from organic lesion, the patient cannot 
be roused by all the efforts which are made; he neither sees nor 
hears anything, nor displays any sensibility to the strongest irritant, 
including fire itself. Coma in the onset of a fever constitutes the 
predominant symptom ; it is of more unfavourable augury in the 



PROGNOSIS. 



565 



advanced stage of disease. That which persists during the apy- 
i rexia would seem to indicate a dangerous lesion of the brain, a 

result which may be brought about by the persistence of even the 

nervous coma. This latter may be accompanied with automatic 
|, and convulsive movements, subsultus and contraction of the limbs; 

all of which are less dangerous than a flaccid state of these parts. 
; In general, coma is more dangerous in old persons, and in adults in 
I the vigour of life, than in children, in whom nervous irritation is 
| easily excited, and who are more frequently attacked with nervous 
1 coma than with other varieties. The eyes in coma may be either 
I closed or wide open, but I am not prepared to indicate with pre- 

cision the different circumstances under which these symptoms are 
I seen. 

Forming part of the prognosis in congestive fevers of the malig- 
! nant intermittent and remittent form, is the question as to their dura- 
I tion, and whether they have not a natural tendency to terminate 
after a particular period. The weight of observation is decidedly 
in favour of there being such a limited duration. I have already 
quoted a passage from Cieghorn, to show the complications of the fever 
which ends in the following terms : " Nevertheless, if death be not 
speedily the consequence of this confusion they commonly again 
put on a more simple or regular form, and after one or more slight 
paroxysms go away of their own accord." And again: " But it is 
much more common to meet with tertians which set out furiously ; 
with subintrant double paroxysm, so that for some days they have 
little or no interval. On the third or fifth day a profuse sweat com- 
monly brings on an intermission; and afterwards the disease as- 
sumes the type of a double intermitting tertian, or of a semi-tertian. 
Such fevers," continues Cieghorn, " I have frequently observed to 
terminate spontaneously on the seventh, ninth and eleventh days, and 
for the most part they are less to be feared." Bailly makes the 
average duration of the periodical fevers in Rome to be between 
fourteen and fifteen days, on a basis of no less than 64,443 febrile 
patients received into the hospitals of San Spirito and St. John of 
Lateran during five years. To the latter institution the conva- 
lescents are taken, and are allowed to remain in it three days after 
they are cured in the first. A similar tendency to a termination is 
manifested in our own congestive fevers on the fourteenth or fifteenth 
day. With equal care in observing the course of this disease with 
that displayed by Cieghorn, we should probably reach the same 
conclusion ; and, like him, express our surprise " at the constancy of 
nature in the production and progress of tertian fevers ; the periods 
being perfectly similar in the Spaniards and in the English, and 
! sometimes not very different in him who lay upon the bare ground, 
I destitute of assistance, and those who are treated in the most judi- 
j cious methods, under every advantage of fortune ; and frequently 
I neither the patient's intemperance, nor unskilful management, can 
| alter their stated course, and prevent their terminating in recovery. 



566 



CONGESTIVE FEVER. 



So much are those mistaken, who imagine that the bent of nature 
in acute diseases can be altered or contracted by every trifling and 
insignificant prescription." With this not very consolatory re- 
flection to the pride of art, I close the consideration of the pathology 
of congestive fever. 



LECTURE V. 

Treatment of congestive fever — Diversified states of the organs requiring variety of 
remedies — Congestion the product of nervous irritation ; may be associated with inflam- 
mation — In the first case, the remedies are to be addressed to the nervous system — In 
the second, to produce organic changes of tissue — Common features of congestive fever 
— Early attention required to the forming stage — Repose and abstinence from all 
stimulants important preparatives — Stage of reaction less marked than in an exacerba- 
tion of common fever — Partial remission and renewal of fever — Subsidence and com- 
plete interval followed by a fresh and violent paroxysm — Commentaries on the 
common modes of treatment — Necessity of attention to the periodical character of the 
fever, and the diurnal period required for completion of the direct effects even of medi- 
cines — Prior habits and exposure of the patient — Treatment required during the stage 
of depression, chill, coma,-&c. — Its limited duration and common termination if left 
to itself — Sydenham's views — Two modes of treatment in the first stage — the power- 
fully stimulating, and the depleting by blood-letting — The true state of the nervous 
system at this time is that of irritation — Soothing and sedative measures preferable 
in this stage — Opium, its good effects in the comatose and cold stage of fever — Case. 

If you have perused with becoming attention the lectures of Dr. 
Stokes on fever in general, and especially in its complications, 
owing to the supervening of congestion or inflammation in an organ, 
you have become acquainted with the chief curative means in the 
treatment of congestive fever, at any rate in that form which is 
displayed, towards the conclusion of the disease. I have taken 
some pains to show that the complication by congestion does not 
serve to designate a fever, so much as it does a modification which 
may occur in any variety of fever and any period of it, and, con- 
sequently, that intermittent and remittent fevers and typhus are in 
cases and stages congestive. So, I may add, isepidemic cholera in a 
remarkable degree ; so also are cholera morbus and cholera infantum ; 
and so are certain forms of small-pox, measles and scarlatina. It 
has been my endeavour, also, to impress on your minds the diver- 
sified precedents and accompaniments as well as effects of conges- 
tion. At one time we see it the simple product of nervous irritation, 
by which the blood is kept in the large vessels, and especially the 
veins, and is not distributed as it ought to be to the small ones and 
the capillary tissue ; then, speedily after, of nervous reaction and 
excitement with expansion, by which various tissues are repleted 
beyond measure and remain surcharged with blood. In these cir- 
cumstances congestion is a purely nervous product, and is removed 
with a change in the state of the nervous system. At other times, 
although the congestion be little more than a local plethora, yet if 
somewhat augmented in consequence even of mere nervous excite- 



,1 



TREATMENT OF CONGESTIVE FEVER. 



567 



] ment, it readily becomes a disease, and the organ which is its seat 
so far suffers as to manifest disordered function ; at first by excess, 
I but very soon, and more enduringly, by weakness and privation. All 
! these instances of congestion are for the most part of a primary 
J nature as regards time, and are met with in the beginning of dis- 
ease. Another, and it is generally thought to be a more alarming 
and sinister variety of congestion, is that which is the result of a 
j permanent irritation of an inflamed organ. Here the congestion 
I may be by direct or by secondary afflux — the first an accumulation 
I of blood in the vessels going to the inflamed organ, as of the coeliac 
! branches in gastritis or hepatitis ; the second, a consequence of 
I irritation transmitted to a weak and enfeebled or highly susceptible 
! organ from another at a distance which is in a state of Mamma- 
's tion ; as in congestion of the brain caused by gastro-duodenitis or 
! by hepatitis. Congestion occurring in either of these two ways is 
usually of later appearance than the others, and is more difficult 
of removal. It could not, it is true, occur without the intervention 
I of the nervous system; but it is maintained in the different changes 
of this latter ; and although still modified by them, it is not, as in the 
1 case of the first varieties of congestion, either entirely caused or 
entirely removed by such changes. Bearing in mind these brief 
premises, which are themselves the summing up of the more detailed 
observations and evidence adduced in my preceding lectures on the 
histories and pathology of congestive fever, you will join me in the 
inference which must greatly influence our practice in the disease. 
' It is ; that in the primitive forms and varieties of congestion with 
fever, we must direct our remedies chiefly to the nervous system 
and its dependencies ; and in the secondary or ultimate forms, our 
measures must be framed with reference to more fixed changes, 
depending on the inflammation and organic changes of tissues. 

In picturing to you the varieties of malignant intermittent or 
congestive fever, distinguished by such formidable features as coma, 
delirium, convulsions, and icy coldness of the extremities, and 
excessive heat and distress in the abdomen, you are not to expect 
to find all or even the majority of the cases of this fever which you 
may be called upon to relieve, thus distinguished. You will find, 
however, the same order of parts affected ; you will meet with 
gastric disorder manifested by nausea, loss of appetite, and alterna- 
tion of thirst and indifference for fluids; pains of the head, back, 
and limbs ; turbidness of the conjunctiva, altered hue of the skin, 
and great inequality of temperature, although the extremities will 
generally be cold whilst there is additional heat of the epigastrium 
and temples, and moisture readily induced intheupper partofthetrunk; 
I the intellect is clouded, senses less susceptible of their customary im- 
I pression ; bowels sometimes costive, sometimes givingfrequent watery 
I stools. It may be, and the circumstance is unhappily too common, 
that these symptoms, indicating the first or forming stage of the disease, 
| will not come under your notice, — the sick person supposing that his 
disorder will soon pass off either with time, or by the assistance of 



m 
1 

508 CONGESTIVE FEVER. 

some domestic prescription. Some from sheer obstinacy ; some from 
avarice, by which they cannot forego the chance of a day's business- 
gains, at the risks of protracted sickness, perhaps even of loss of 
life itself; others, and they are to be pitied, from a fear of the de- 
privation of the money for their daily toil, by which their families 
are supported: all of these several classes of persons are back- 
ward, both in abstaining from habitual occupations, which only bring 
the disease into complete development, and in procuring suitable 
professional counsel for the removal of existing symptoms. Hence, 
in, perhaps, a majority of cases, the most valuable time for check- 
ing the disease is allowed to pass away, and the physician is not 
sent for until the patient has had a chill, and suffers from the fever 
which marks reaction. It is greatly to be wished that people 
were fully aware of the great mischief which a man does to himself by 
his going about during the impending and forming stage of fever — at a 
time when the nervous system requires repose, at least to be abstracted 
from its habitual stimulants of mental occupation, light and sounds. 
In health the heart is quickened, we know, many contractions, by 
the mere change from the recumbent to the erect posture, as 
evinced in the differential pulse : and hence the feeling of languor, 
amounting sometimes to syncope, in persons of a weak frame who 
are kept standing a long time. How illy then can the heart, 
irritated as it is by the excited nervous system in the inception of 
febrile disease, bear the additional strain upon it of an erect posture, 
and perhaps of muscular exercise superadded. Repose and a 
reclining posture are of the first necessity for an ailing person, 
whose instinct alone would lead him to seek them, were he not 
prevented by the suggestions of false reason and intense selfishness. 
Next to these, and as a necessary measure of comfort, tight clothes 
and ligatures of every description should be at once removed, and 
a covering for the body substituted, of such texture and amount as 
shall contribute to the restoration of an equable temperature. With 
this latter intention simple warm drinks should be taken ; and if the 
rigors be frequent, a warm bath, or in its place a warm pediluvium. 
As the chief irritation at this time, and, indeed, the chief functional 
disturbances, are in the series of organs contained in the abdominal 
cavity, and which are governed chiefly by the ganglionic or nutri- 
tive system of nerves, it is exceedingly desirable that no false step 
should be taken at this time to increase the irritation and to compli- 
cate the disorder in this region. Hence, we enjoin abstinence 
from all stimulants and especially from nutritive ones ; the ex- 
citement from which, beginning at the gastro-intestinal mucous 
surfaces, is continued through the aborbent, circulatory and secret- 
ing apparatus, as well as the lungs and nervous system, and lasts 
at least during an entire diurnal revolution, or twenty-four hours. 
He who should feel inclined, or be on the point of yielding to 
the persuasion of another, to eat any substantial food, after he 
feels any of the premonitory symptoms of fever, ought to be 
reminded of the strong probability of the disease being aggravated 



REACTION IN COMMON CONGESTIVE FEVER. 569 



by this excitement of all the organs whose functions are already 
| impaired and which require repose, and that what he eats at a 
given hour to-day may tell against him at the same hour on the 
following day. It is of far greater importance for persons generally 
to be able to appreciate the signification of the first symptoms of 
! fever, and when this is learned to abstain at once from all kinds of 
j excitement, intellectual or bodily, sentimental or sensual, than for 
1 them to have learned how to use certain remedies with a view to 
j check or cure the disease. But even this is not a fair statement 
| of the proposition : the first point of knowledge would be of most un- 
equivocal benefit, — the second is commonly mischievous. 

We will suppose, now, that professional assistance is regularly, 
and if so, urgently invoked, and that the physician visits his 
I patient in the stage of febrile reaction after the chill is over. If it 
were a case of regular intermittent he would expect to find a full, 
j bounding pulse, with a slight thrill; skin unusually hot; throbbing 
temporal and carotid arteries; flushed face; lustrous eye; headache; 
I hurried and oppressed breathing, — perhaps sickness of stomach, at 
i any rate, intense thirst, restlessness, intolerance of all stimuli, and 
sometimes delirium. If it were a paroxysm of regular remittent fever, 
he would find nearly the same symptoms, with still more gastric 
irritation — all indicative of expansion of vitality and dilatation 
of the tissues, including the most external and superficial ones. 
Sometimes the head and sometimes the stomach is the organ 
I chiefly suffering ; the bowels generally being costive, and when ex- 
cited by active purgatives evincing no inconsiderable irritation. 
Impatience is the predominant expression of the sick person in 
I this hot stage of common intermittent, or regular remittent fever. 

But in your case of congestive fever you must not expect to find 
I complete reaction. This term is, in fact, merely comparative, as 
distinguished from the general torpor, perhaps icy coldness, which 
preceded it. The pulse does not beat with such fullness and re- 
sistance as in the instances of the paroxysm of regular intermittents 
and remittents — it is frequent and small, or voluminous and without 
force ; or, if reacting under the finger, it wants regularity and, what 
may be called, equable volume. The skin is dry, of a murky or 
deep red — sometimes brownish hue; temperature unequal, being 
j rather above the standard over the chest and abdomen, and often 
j below it on the hands and feet and lower limbs generally. The 
I stomach is sometimes distressed, — much thirst and heat being 
present, — sometimes nausea and sickness without the two former 
! symptoms. The eye is tumid and dull, or occasionally injected : 
| restlessness and delirium will alternate with decubitus on the back 
and somnolency. The chief expression of the face is that of mis- 
! trust diminishing into indifference. In some, in whom the powers of 
life are vigorous, and the causes of the fever have not been of long du- 
ration, the reaction would approach more to that of common inflam- 
I matory remittent, but even here the skin is more puffed — the evidences 
| of oppression are greater, and the diffusion of heat over the entire 

49 



570 CONGESTIVE FEVER. 

surface is seldom well marked. After a period of varying duration 
there is an abatement of the functional distress and a remission, 
indicated by sweat, but which, unlike the general warm and free dis- 
charge in regular intermittents, and the warm but less free in 
remittents, is, in the case before us, partial and viscid, — being 
chiefly on the trunk and neck and part of the head. We are not, 
however, to expect such contrasts in this symptom in all, or in 
even a majority of cases ; for, as I have already shown, there is 
occasionally in diseases of great congestion an abundant warm, 
watery sweat, which, however, fails to give relief. I think that 
this symptom is much more common in cases of pulmonic conges- 
tion than in the abdominal, which is the most usual variety, at any 
rate when the fever assumes an epidemic character. 

If the case be one of malignant double tertian, which has come i 
on in the early part of the day, we may expect a mitigation of the 
symptoms towards evening and in the night. Then, on the fol- 
lowing day, a renewal of the paroxysm, which is sometimes unac- | 
companied by any sensation of coldness, and is indicated chiefly 
by increased pain of the head, distress of stomach and general i 
restlessness, or the reverse, of fixed posture and approach to 
somnolency. This stage may last in its turn for a period similar to 
the first or even longer, and end by a more complete crisis in a 
tolerably abundant sweat. A calm is now established; the patient 
complains of little else than languor and a slight headache ; his 
tongue is moist ; thirst gone, and he craves food. Perhaps if he 
have been left to his own guidance during the preceding tertian 
period, he may think that convalescence is begun — he calls for a 
bowl of rich soup, or eats of some highly-seasoned meat ; quaffs his 
glass of wine or of spirits and water, and talks confidently of the 
business which he proposes personally to superintend in person on the 
morrow. Alas! short-sighted man, he may never see another day. | 
Ere he has well concocted any one of his schemes, he feels pains in j 
his head and limbs, with some numbness in his extremities, soon fol- j, 
lowed by general coldness, violent chills, sinking strength, small and 
almost imperceptible pulse, and coma ; in fine, a return of the con- j 
gestion, but in a more aggravated form, and corresponding with that 
of the paroxysm two days before, at the same hour. Sometimes the j 
tertian period is completed by the coming on of a slight chill, followed 
by a very imperfect reaction, in which delirium and convulsions are j, 
predominant symptoms. The term subintrant is applied to the quo- [ 
tidian or double tertian, in which the intervals are so short be- 
tween the paroxysms that it has the appearance of being continued • 
fever. , 

With the various stages and aspects of congestive fever now be- 
fore us, something may be said with advantage on the treatment of 
this disease. I shall not, however, at this time attempt to lay 
before you a systematic and detailed view of the points of practice 
advocated at different times in other countries, nor even of all those \ 
which are current among us here at home. An elaborate attempt 



I 



GUIDING POINTS IN THE TREATMENT. 571 

I 

j at method on such an occasion must be artificial, and of course 

confusing and erroneous. If I express doubts of certain heroical 
! modes of treatment, it will not be with the intention of making you 

less energetic at the moment of trial, but with a hope that you will ac- 
| knowledge the powers of nature, in the regular and inevitable recur- 
I rence of certain phenomena; and that you will not assume the series 
j of natural changes in the disease to have been brought about by your 
1 remedies, which last, at the juncture, may have been either inert, 
' or whose operation was opposed to the desired results. 
| There are some leading facts which must be borne in mind when 

we undertake the treatmeut of a case of congestive fever. One 
j relates to the disease itself, viz.: its periodical character and the 

succession of its stages, its becjinninsr, increment, and remission or 

. . 0*0.0' ' 

I crisis, the repetition of which from day to day, or on alternate days, 
makes up the entire period of the disease. Another is the prior 
habits and length of period of exposure to the causes which have 
brought on the fever. The third is the series of effects produced by 
any one active remedy, and which are rarely completed within the 
period of a diurnal revolution. A distinct perception of the first fact 
will prevent both the excessive alarm which the symptoms, taken 
j apart from their precursory and subsequent connexions, would cause; 

and next the excessive haste and prodigality in administering various 
j and potent remedies for the removal of these symptoms — a result 
I which nature herself, or rather the periodical rhythm of the animal 
i economy necessarily tends to bring about. The second fact, or that 
which refers to the prior habits and length of period of exposure to 
the causes of disease, will modify greatly our treatment. Thus, if 
we find that our patient has been habitually intemperate in eating 
and drinking, and especially in the latter; — or that his life for some 
time past has been one of toil and anxiety, exposure to solar heat, 
and contrasted atmospherical operations, and diminished period for 
sleep, &c, we must not expect that he can, even though possessed 
of a large and muscular frame, be able to bear either the shock 
of the fever, or the counter-shocks of very active remedies in very 
activedoses, as well asapersonof different habits, and whose exposure 
has been slight. The third guiding fact, that which more directly in- 
fluences us in the repetition of remedies, is one very generally, if not 
universally overlooked. A definite, though not uniform period, must 
elapse before a medicine can be said to produce its full and desired 
effects on the system at large, by operating on a series of functions, 
which, beginning with those of thegastro-intestinal mucous membrane, 
are only terminated by secretion. Ournotions of the extent, if not kind, 
of operation of a remedy, are entirely too restricted. A person with 
a full and somewhat frequent pulse is bled, we will suppose, this 
morning — the urgent symptoms are mitigated in consequence ; there 
is even a kind of reaction, in which the pulse acquires somewhat 
more volume, and the skin becomes soft and moist; the evening 
exacerbation is mitigated. The patient passes the night tranquilly, 
and the morning finds him without any particular complaint, except 



572 



CONGESTIVE FEVER. 



headache and some languor and nervousness. During the day- 
he is also free from any notable derangement of function ; but the 
physician, on feeling the pulse, discovers it to be easily compressed 
and smaller than natural) and the skin to be too cool, and a cold 
moisture to be spread over it. Not liking the symptoms, he recom- 
mends wine-whey, animal broth, and, as the evening approaches, 
strong diffusible stimulants. But the symptoms of depression in- 
crease, sweat oozes from the skin, the pulse fails, and by the next 
morning the patient is moribund. How little, in such a case as this, 
can the real constitutional effects of venesection be ascertained 
during the period which first succeeds the operation. There are, it 
is true, two orders of effects produced by- blood-letting, — the first and 
immediate, consisting in the relief of an organ, as of inflamed lungs, 
by the abstraction of blood which oppressed by its quantity ; the 
second more varied, complicated, and slower in being produced, is 
the change in the functions generally, including those of the 
nervous system. 

I might illustrate the position now laid down for your instruction, 
respecting the order of succession of effects resulting from the opera- 
tion of a remedy during a much longer period than is generally 
admitted, by referring to the effects of opium. It is given, we will sup- 
pose, in the evening in order to procure sleep, but often only acts on the 
patient in this way towards morning; and he is still in the early part 
of the day under its narcotic and diaphoretic influence, when he is 
purged, or bled, or blistered, and, in all these cases, under a suppo- 
sition that the system is open to the regular anticipated effects of 
this kind of operation. Left to himself instead, — he would probably 
be in a diaphoresis during the whole day, with the aid, at any rate, 
of nothing more than simple tepid, diluent drinks; and as night 
approached, and his skin became dry, he would complain of head- 
ache — this symptom being hardly the completion of the diurnal 
circle of functional operations and changes resulting from the opium, 
which was begun twenty-four hours before by a slight increase of 
arterial action and pleasurable nervous excitement. If necessary, 
I could point out equal imperfection of view in regard to the little 
time given for the completion of the series of effects produced by 
-emetics, purgatives, diuretics, and diaphoretics. Commonly, the 
material measure, or that of quantity, is made to represent the physio- 
logical measure of the operation of the medicines of these several 
classes — to the no small detriment of the patient, and interference 
with his restoration to health. How restricted, for instance, that 
idea of the effects of calomel which only includes its operation on 
the bowels and the liver. This medicine producesdistinctimpressions 
and characteristic effects on the stomach, which it first soothes, and 
sometimes, on reaching the pylorus, nauseates; then on the small 
intestines, in allaying irritation and modifying their mucous secretions. 
On reaching the ileo-ccecal valve it often sickens, but in a manner 
very different from the common emetic. On the colon it has also its 
peculiar operation, in not only discharging the contents, but in modi- 



NATURAL TERMINATION OF PAROXYSM. 573 

fying the secretions of the intestine. The liver is not the only organ 
| which is sympathetically affected during and after this time — the 
kidneys, lungs, and the skin are acted on in a marked manner. 
Thirty -six hours is not a longer period than must transpire before 
the series of direct effects of calomel are over. 

After these preliminary precautions, which are susceptible of 
| varied and fruitful application to more diseases than congestive 
fever, I shall proceed to a critical yet desultory notice of the 
curative means to be employed in its several stages. To a physi- 
cian who should see for the first time a person in the cold stage 
| of intermittent fever, few morbid states would be more alarming 
and seem to call more imperatively for immediate relief. How 
much greater the danger must seem, and urgent the demand for re- 
storation, in the comatose, delirious, convulsive, and cardiac varieties, 
j a continuance of any one of which seems to threaten to extinguish life 
j at once. But a little experience soon assures us that the chill of a 
common intermittent will not be long in passing away, and in 
being replaced by its opposite, of excessive heat, — which in its turn 
| is followed by moisture and tranquillity — intermission and partial 
i restoration to health. Similar, though from the infrequency of the 
case more limited, experience tells us that the coma which amounted 
almost to apoplexy, or the delirium, will, also, subside and be fol- 
lowed by fever and diaphoresis — but with less distinctly revealed 
symptoms and often less satisfactory intermission than in common 
periodical fever. That experienced practitioners have been con- 
I tent to wait for the natural termination of the stage of stupor, 
comatose or apoplectic, by which the paroxysm of some congestive 
fevers are ushered in, is obvious from the language of Sydenham 
on reference to such an event. After telling us that " the fits did not 
begin with chillness and shivering, which was succeeded by a fever, 
but the patient was seized with the symptoms of true apoplexy, — 
though, in reality, how nearly soever it resembled this disease, it 
was nothing more than the effect of the fever's seizing the head; 
as plainly appeared from other signs, as well as the colour of the 
urine, which, in intermittents, is mostly of a deep red (but not so 
red as in the jaundice), and likewise lets fall a lateritious sediment," 
this celebrated man goes on to say: "Now, though in this case 
all kinds of evacuations seem to be indicated in order to make a 
revulsion of the humours from the head, as is generally practised 
in the genuine apoplexy, yet they are to be wholly refrained from, 
because they are very prejudicial in the intermittents, whence this 
symptom originally proceeds, and consequently endanger life, as I 
have observed. On the contrary, therefore, we must wait till the 
j fit goes off spontaneously, when the bark (in case it could not be 
given sooner) must be immediately exhibited, and carefully repeated 
| in the intervals, till the patient be perfectly recovered." 

The probability of spontaneous recovery or rather of restoration 
from the first fit of irritative depression, that is, of depression by 
excess of irritation, is greater than that of revival from the second 

40* 



574 



CONGESTIVE FEVER. 



and subsequent ones. In the comatose case of intermittent fever, 
which I treated by local depletion from the abdomen and head in 
the manner already detailed, the revival, although it might seem to 
be a direct effect of the depletion and revulsion thus obtained, would, 
I am inclined to believe, have occurred, had no remedies been used 
during the fit. But supposing that we are required by our views 
of the case to have prompt recourse to recuperative means, — the 
question already presents itself : What are they to be 1 Those of 
a powerfully stimulant kind, which may rouse the dormant energies 
of the nervous system to reaction, and enable, by its irradiation, the 
suffering organs especially to throw off the load that oppressed 
them ? Or to equalize the circulation by the abstraction of a por- 
tion of this load, the accumulated blood in the deeper seated viscera, 
so as to allow the heart to propel this fluid with more ease, 
and the brain and nervous system generally to receive the 
genial and appropriate stimulus from the now changed vitalized 
blood after its complete passage through the lungs? I shall de- 
vote a few observations to each of these modes of treatment, 
which have, severally, their advocates and practisers. Re- 
course to strong stimulants internally, and irritation externally in 
congestive diseases, including both congestive fever and epidemic 
cholera, — between the leading symptoms of which there is often con- 
siderable resemblance, has arisen from an imperfect knowledge of 
the condition of the nervous system during the paroxysm. This 
latter has been supposed to be enfeebled and depressed, and inner- 
vation consequently deficient — whereas it is, in fact, excited, irritated, 
and, we may add, perverted. True depression of the nervous sys- 
tem and suspended innervation, as in syncope, exhibit very dif- 
ferent symptoms from those in congested fever. So far from the 
skin being pale and colourless as it is in the first case, it is always 
of a morbid hue, which is of itself indicative of an active and per- 
verted state of the nervous system. The coldness which often ac- 
companies a congestive state is part of the effects of a benumbing, 
as it were, from excess of irritation, such as would ensue on striking 
or contusing a nerve, or on concussion of the brain ; and is different 
from the simple exhaustion and wearing out of its sensibilities. As 
I have elsewhere said, when treating of the phenomena of cholera, 
(All the Material Facts in the History of Epiae?nic Cholera, fyc, by 
John Bell, M.D. and D. Francis Condie, M.D., 2d Edit., J832 ; ) "the 
very excess of innervation, or of nervous distribution and supply, 
will closely simulate to the eye of a superficial observer its absence 
or deficiency. Take, for example, a person under the influence of 
violent pain, as of pleurisy, gastritis from irritating poisons, burns 
of the skin, or even paronychia, and his nervous system will be 
found in the highest degree of excitation and irritation — and on this 
very account he will be seen with a pale and almost livid counte- 
nance, sharp features, small threaded pulse, cold and clammy skin, 
or perhaps in a cold watery sweat, and with excessively hurried 
and laborious respiration. The secretions are scanty or even sus- 



MILD STIMULATION PREFERABLE. 



575 



pended — and yet no one, in these cases, who is conversant with 
pathology and the treatment of disease, would think of still 
farther urging and stimulating the nervous system, under the idea, 
by this means, of restoring the secretions, and relieving the oppressed 
circulation and respiration." In another page of the work just 
quoted, I said: " Innervation is, as we have seen, in excess, despite 
the deficient supply of arterial blood in the nervous centres. The 
circulation is, on the contrary, sluggish, impeded, almost arrested, 
! both at its central organ, the heart, and its peripheric instruments, 
1 the capillaries. They are not both torpid or dead for the time 
| being, as in syncope and some analogous states of the body — nor are 
they both active and morbidly excited as in the phlegmasia? and 
i inflammatory fever. A strong evidence, and at the same time effect, 
of this interrupted harmony of action between the nervous and 
i vascular systems, is deficient calorification. This process requires 
both innervation and capillary circulation — the former is a prime 
agent, but it is incompetent to produce the effect without the latter. 
One of our objects then in the employment of remedies, is to restore 
this harmony, to get the capillaries to act, and to be filled — in fine, 
to be placed in that state which we find them in the hot stage, or 
that of reaction, in intermittent fever. We are even fain sometimes 
to run some risk of inflammation, to bring about so desirable a re- 
sult. Confounding in one the two separate states of the nervous 
and vascular systems, in the cold stage of intermittent fever and 
in the depression or collapse of cholera, attempts have been made to 
( produce reaction of the circulatory apparatus by a prodigal use of 
stimuli. Sometimes they have succeeded — oftener they only serve 
to provoke a still higher degree of neurosthenia, and thus to retard 
reaction of the capillaries — -or, if this takes place, it is hurried on by 
these remedies into a fixed phlegmasia of the membranes — digestive 
mucous, and pulmonary mucous." 

The unequal temperature of the body-— coldness of the extremities, 
and heat of the abdomen, — the pain and internal distress amounting 
almost to agony ; the stiffness and immobility of the limbs; — all evince 
a concentrated irritation of the nervous system: farther proofs of 
which may be cited in the small or laboured pulse, and oppression 
at the precordia. The indications of cure are to allay, not to ex- 
cite — to soothe, not to perturb. The warm bath, mild and continued 
frictions over the whole surface of the body, particularly on the 
inside of the limbs, along the spine and abdomen and chest, and 
tepid or cool water for drink if the patient craves it, together with 
opium in small doses, or laudanum with camphor water, are 
the remedies to correspond with this view. In favour of milder 
stimulation of the skin, rather than hot baths and caustic and ex- 
' coriating applications, I may mention a curious physiological fact, 
elicited by galvanic experiments in two instances made on the 
bodies of men who had been hung. To those on the first, in this 
city, I was myself a witness: — the second were at Lancaster, 
Pennsylvania, and were observed by a number of professional gen- 



576 



CONGESTIVE FEVER. 



tlemen assembled on the occasion. It was discovered, contrary 
to h priori reasoning, that the contractions of the muscles of the 
face, chest, and limbs, were more active and complete when the 
galvanic poles moderately charged were applied by running them 
over the sound skin, than when directly to a nerve denuded for the 
purpose (Eclec. Jour, of Med., Oct. 1839. Am. Jour, of Med. Sc., 
May, 1840). It is clear then, that the nervous system, in order to be 
roused to action, and made to develop its dormant excitability, 
must be appealed to at its peripheric expansion and over an extent 
of surface and by mild stimulation, rather than at its cords and 
by potential irritants at any given point. More benefit will be 
gained by the assiduous application of mild frictions over an extended 
surface than by large blisters and sinapisms. The latter at first 
have no effect in rousing the sensibility of the skin so long as the 
nervous system is in its state of numbness — and if they subsequently 
excite, the excitement is not in relation with the condition of the 
system, and is but evanescent. The experience of those physicians 
who had cases of cholera to treat is tolerably conclusive on this 
head; nor will that in congestive fever be of a different nature. 

The same reasoning should guide us in the administration of 
remedies internally — with this difference, that the mucous surfaces 
are not only labouring undernervous irritation, but also inflammatory 
congestion; both of which states will only be aggravated by stimu- 
lants, whose action is intended to be general and diffusive. The 
following case, which, with others, is reported by Dr. Johnson of 
Fort Gaines (South. Med. and Surg. Journ., Vol. I.), is illustrative of 
the view which I now lay before you: "About sunrise on the 
morning of Sunday, in the month of August, 1835, a negro boy, 
aged 30, belonging to one of my patrons, was attacked with pain 
in the head and shivering. He was ordered to bed, and wrapped 
up warm, and a bowl of hot sudorific tea was given him. The 
boy complained no more, and lay in bed perfectly calm and quiet 
until eight o'clock, when his master became alarmed, he said, at 
his breathing, approached the bed, and called out to him. The 
boy returned no answer. He threw the covering from his 
head, and was still more alarmed at the boy's appearance. His 
eyelids were thrown back; his eyeballs immoveably fixed; his ex- 
tremities cold and clammy, and his pulse slow and struggling. The 
boy seemed to notice nothing. I was immediately called in with 
Dr. Henson. We had the boy immersed in a hot salt bath, and 
gave him camphor, aether, and cognac brandy, and a strong infusion 
of capsicum internally; made use of sinapisms to the extremities 
and spine, warm stimulating fomentations to the epigastrium, and 
clysters. Notwithstanding this plan, together with a large vesi- 
catory over the region of the liver, the boy appeared to get no 
better, and died in a few hours. Permission was granted me to 
make a post mortem examination of his head, and I was not privi- 
leged to extend the examination farther. On opening the skull, the 
only unnatural appearances of the brain were the enormously dis- 
tended and engorged state of its vessels — clearly proving to my 



IRRITATION RELIEVED BY SEDATION. 577 



satisfaction the cause of his death." As the whole narrative is 
short, I have introduced both the notice of the symptoms which pre- 
I ceded the treatment and the appearance of the brain as far as 
' examined after death. We see that all the strong stimuli so pro- 
fusely administered both externally and internally had no effect 
whatever in rousing the torpid excitability of the patient. I cannot 
but think that in this -first stage of congestive fever, the stronger the 
! stimulus applied, the greater the probability of its producing an effect 
\ on the nervous system analogous to its then morbid state or one of 
| painful irritation, the very excess of which had produced the numb- 
ness and torpor which, impose on some for prostration and exhaustion. 
| But in speaking of numbness and torpor, I apply these terms to the 
condition of the encephalo-spinal portion of the nervous system, or 
that of animal life. The centre of irritation, that from which it 
radiates, is the abdominal nervous system, which makes up so 
important a part of that of organic life. Here the irritation is 
persistent, and is manifested by the activity of abdominal circula- 
tion, the pulsation of the aorta and its cceliac and mesenteric 
branches, increased afflux of fluids, and even congestion in the 
mucous membranes, liver, and spleen, and increased and perverted 
secretions from the stomach, intestines, and liver. It is the con- 
tinued irritation in this region, which, transmitted to the brain, slowly 
it is true, because circuitously and through the plexus and ganglions 
of the sympathetic, fatigues this organ and finally produces the 
, state of coma, or of coma alternating with delirium and convulsions, 
which marks the worst form of congestive fever in its early stage. 
If this be correct pathology, then are stimulants, except of the m.ild- 
est kind, such as warm teas, inadmissible; and a still farther and 
more direct conclusion is, that opium, or some one or other of its 
preparations, is demanded by the nature of the case. What ! it will 
be exclaimed by some, — give opium, a narcotic, in a state of 
apparent apoplexy, or stupor which may be said to resemble that 
of narcotism? If the visceral congestion and the distended vessels 
of the brain were primary phenomena, and were not in the begin- 
ning, at any rate, effects of a disturbed nervous system, it would be 
rashness to give anything which might augment such a condition of 
the organs : but, as I have already more than once informed you, all 
these congestions and injections of tissue will often entirely disappear 
with the removal of the paroxysm, which, as far as we can see, is 
accomplished through the intervention and by the direction of the 
i nervous system. If, therefore, we have any means of acting on it 
| in a definite manner we control quoad hoclhe congestion, by either 
preventing its occurrence or carrying it off. In the circumstances 
now under consideration my pathology is in harmony with thera- 
j peutical experience, which points distinctly and emphatically to 
i opium as one of the best, if not the very best and safest remedy 
prior to the coming on and actual supervention of the alarming 
! state of congestion which distinguishes the paroxysm in malignant 
j double tertians or the congestive fevers of our country. By allay- 
ing and subduing the morbidly excited state of the nervous system 



! 



578 



CONGESTIVE FEVER. 



of the abdomen, this medicine removes the cause of cerebral irrita- 
tion, and with it the dependent symptoms : it places also the nerves 
and blood-vessels in harmonious relation to each other, acts power- 
fully on the capillaries, — not of one or two organs merely, but of the 
whole body ; one evidence of which is the evolution of caloric in an 
active degree from every part, and notably from the skin, which 
recovers its perfect vitality, is fuller and softer, and secretes healthy 
sweat. In place of partial and therefore dangerous congestion, 
and an accumulation particularly in the venous system, there is a 
temporary turgescence of all the tissues and equable activity of the 
circulatory apparatus at large. The mucous membrane of the 
stomach and bowels soon evinces the general influence of the opium 
in a suspension of its irritative actions, — heat, pain, and morbid, 
secretions, — and, soothed itself, it now ceases to disturb other organs 
— the heart, brain, and lungs. In fine, there will be a solution of the 
paroxysm, with a warm, copious sweat, and a natural sleep. Even 
if there should be a slight narcotism, this state will be an advantageous 
substitute for that morbid one of irritability of the nervous system, by 
which it was disturbed in so many various ways; and time is allowed 
for the functions to be balanced, and to begin once more their harmo- 
nious course. Not only in the onset of the comatose, delirious, and 
convulsive varieties of congestive fever, but also in those mild yet still 
dangerous cases in which the temperature is unequal, hot head and 
epigastrium with cold extremities, small and irregular or intermittent, 
and otherwise laboured pulse, opium will contribute to equalise ex- 
citement and bring on salutary reaction. Even after this latter has 
begun, if the skin is dry and rough, and the nervous element still 
prevails over the vascular, opium will aid in accelerating the 
course of the last stage, and in bringing on a critical sweat. Lind 
says he has used opium with decided benefit in the hot stage of three 
hundred cases of intermittent fever. His prescription was fifteen 
to twenty drops of laudanum with two drachms of syrup of pop- 
pies. 

Opium, on occasions so beneficial during the first and even second 
stage of the paroxysm of congestive fever, has been used with 
good effects to prevent its accession at all. For this purpose it should 
be given some time before the fit, or if opportunity is not allowed 
for its administration thus early, it ought to be so soon as the 
wandering pains in the limbs and trunk, headache, some rigors 
and nausea, furnish premonition of the expected paroxysm. In this 
case a full dose, as of sixty drops of laudanum, or a grain of the 
sulphate of morphia, may be given at once to an adult. When the 
paroxysm has come on, and the coldness and stupor are great, 
the propriety of a large dose, though it might seem to be justified 
by the apparent insensibility of the system, is not so clear. The 
plan which I should prefer, would be to administer, under these cir- 
cumstances, five drops of laudanum in a table-spoonful of camphor 
water every five minutes until evidences of producing an impres- 
sion on the system by a slight reaction, and some little abatement 
of the symptoms were seen ; — then we might give a fuller dose, 



OPIUM IN THE DEPRESSED STAGE. 



579 



say thirty drops at once, and wait the result as far as relates to in- 
ternal medicines for this period. Moderate, but continued and ex- 
tensive friction with a warm hand or warm cloth, and a soft brush 
dipped in warm salt and water, should be had recourse to at the same 
time, in order to encourage the expansive action of both the nerv- 

I ous and vascular systems. The dry vapour bath, as of alcohol and 
simple warm air, are sometimes preferable to the warm water 
bath. In cases in which the individual is unable to swallow, the 
laudanum or solution of sulphate of morphia may be given by the 

| rectum, in a small quantity of simple water rather than of muci- 
lage, the more readily to insure its action on and absorption by the 
mucous surface of the rectum. If we admit the propriety of divided 
doses, twenty drops may be given every half hour until a hundred are 
used in this way. The union of lac assafoetida will add to the good 
effects of the laudanum on the brain. Let me introduce a piece 
of advice for your guidance in the sick room, when you prescribe 
laudanum, or any active medicine by enema. It is ; either to admin- 

| isteritthe first time yourself, or to be present during its administration, 

j so that you may be sure of your advice having been carried into 
effect in this particular. Without you are thus attentive and 
precise you cannot tell positively, whether the medicine which you 
have prescribed has been used at all in the manner you wished — and 
you often are left to wonder at the want of a success of a remedy, 
which is entirely attributable to its not being properly or at all ad- 

I ministered. How often is a physician, when in attendance on a case, 
in which he is very desirous of procuring free evacuations from the 
bow 7 els, mortified by the reply of the nurse, that no discharge has 
followed the use of the purgative enema which he had directed. 
On inquiry, he learns, at last, that the infusion or mixture, whatever 
it may have been, was never properly passed into the rectum and colon 
at all — owing to the want of a proper instrument, or to the ignorance 
of the operator. 

Among the cases of the curative effects of opium in a comatose stage 
of malignant tertian, is the following from Wirtenson quoted by 
Bailly: 

On the second attack of fever, which, like the first of the preceding evening-, 
came on at eleven o'clock, a lady, who was the subject of it, fell into a profound 
coma, losing both speech and sensation — her eyes were open and fixed, her limbs 
stiff as in catalepsy; the pulse was small and intermittent, the respiration labo- 
rious. All the persons around expected death to close this scene in a short time. 
With a hope, however, of giving relief, some physicians recommended emetics, 
irritating enemata, or the application of blisters; in fine, recourse to stimulating 
' remedies. But Dr. Hoffmann, who, happening to be on the spot, was called into 
j consultation, had no confidence in the measures suggested, having in other cases as- 
certained their inefficacy. Still as there seemed to be no room for temporizing, 
I and as the necessity of the case was urgent, he determined to make trial of opium. 
| He accordingly poured into the mouth of the patient ninety-five drops of laudanum, 
j which he saw her swallow. After a few minutes the pulse was developed and 
! the breathing more free ; and in less than half an hour the danger was over, together 
with the lethargy the pulse became full, the limbs had regained their supple- 
j ness, and the patient recovered her consciousness and began to speak. Febrile 
heat was evolved, and sweat, which followed in a few hours afterwards, put an end 



580 



CONGESTIVE FEVER. 



to the paroxysm. Bark was prescribed for the following day, but owing to the 
nausea, similar to that which had distressed the patient between the first two 
attacks, this medicine was rejected after every time at which it was swallowed. 
Vinous decoction and the extract of the bark were also thrown up from the stomach. 
Enemata of bark had not the desired effect. On the following evening the parox- 
ysm returned at the same hour and w 7 as marked by the same alarming symptoms 
as before. Laudanum was forthwith given, with the same results and with the 
same success as on the former occasion. During the next, and succeeding days, 
the vomiting and disorder prevented the use of the bark by the mouth, and its only 
mode of administration was by enemata. Fears were naturally entertained that 
a third paroxysm would supervene; and the husband of the patient, who had been 
a witness to the efficacy of the laudanum on former occasions, asked if it would 
not answer to give this remedy an hour before the expected accession. The sug- 
gestion was adopted, and its success was most satisfactory. The paroxysm came 
on, but without any alarming symptoms. After it was over, the patient was able 
to take the infusion of bark in wine, and in a few days she was entirely cured. 

Here I close this lecture. In my next, I shall inquire into the 
arguments in favour of blood-letting in the first or cold stage of 
congestive fever. 



LECTURE VI. 

Treatment of congestive fever continued — Proposal to equalise the circulation by the 
abstraction of accumulated and congested blood is based on too physical a view — 
The other alleged indication, to remove venous blood deleterious to the organs is not 
physiological — Experiments of Edwards — Congestion an effect and a symptom, not 
a cause — Blood-letting not called for in the premises—Cases — Reaction after bleeding 
in the depressed stage an evidence of remaining vital power, and not of the efficacy 
of the remedy. — Blood-letting useful in congestive fever during the febrile reaction, 
if there is inflammation of some organ — Modes of abstracting blood — Topical, as 
by leeches and cups with scarificators — Dry cupping — Immediate effects of blood- 
letting — Its mode of action — Fallacy of judging from symptoms of reaction — Necessity 
of removal of irritants from the alimentary canal with reference still to the phlogosis 
of the mucous membrane — Milder means to be preferred — Enemata — Emetics when 
indicated — Emetics and dry cupping — Purgatives — calomel, castor oil, and spirits 
of turpentine — Action of the turpentine — Treatment in the exacerbation of conges- 
tive fever — High febrile reaction sometimes rapidly subsides into extreme debility — 
Blood-letting — cold affusion — cold drinks, simple and acidulated, or slightly bitter — 
cold enemata — Purgatives to be avoided at this time — Saline preparations largely 
diluted in simple fluid, and taken as a drink — Secretions restored by these means. 

I have endeavoured to show by the pathology of the cold stage 
of congestive fever that stimulating remedies are not those which 
are called for; and, next, I have pointed out the failure of such 
remedies and contrasted the treatment by them with that of a 
soothing and sedative nature, greatly, as I think, to the advantage of 
the latter. The other method of treatment I stated to be advo- 
cated on the ground of equalizing the circulation by the abstraction of 
a portion of the accumulated blood in the deep-seated viscera, so 
as to allow the heart to propel this fluid with more ease, and the 
brain and nervous system generally to receive their genial and 
appropriate stimulus from the now changed and vitalized blood, 
after its complete passage through the lungs. That view is, I think, 
too purely physical which supposes the morbid phenomena to depend 
on a simple accumulation of blood in the chief viscera and larger 
vessels, particularly the veins. Congestion being manifestly and 
avowedly the product of a prior morbid change in innervation can 



ERRONEOUS EXPLANATIONS OF CONGESTION. 581 



not be materially mitigated by an abstraction of blood. The nervous 
system, remaining in the same morbid state or retaining its mor- 
bid susceptibility to periodical irritation, is as capable of causing 
sanguineous or venous congestion with a small as with a large 
I quantity of blood. It is not so much the amount congested as 
the inequality in circulation, and in the other functions implied 
I by this fact. So much for the merely physical part of the argu- 
j merit. The common physiological explanation of the cause of op- 
| pression and temporary suspension of the functions of the nervous 
i system, and of the feeble action of different organic apparatus, 
! is no better founded. It supposes a sedative and poisonous effect to 
be produced by the venous or carbonated blood retained in and 
applied to the organs, in place of the arterial and decarbonated and 
oxygenated blood brought to them in a common and healthy state 
of the circulation. Such was the explanation of the phenomena of 
asphyxia and of analogous or"approximating states of the animal 
economy in certain diseases and stages of particular diseases. 
I More recently, however, it has been shown by Dr. W. F. Edwards, 
1 in his admirable work on the Influence of Physical Agents on Life, 
which I introduced into the Select Medical Library, that venous 
blood, so far from being thus deleterious and destructive to the 
functions of the nervous and other apparatus of function, enables 
them to retain their characteristic modes of vitality much longer 
than when the blood has been entirely withdrawn, as by excision of 
the heart and great vessels. If, then, we design to lessen the quantity 
I of blood in the system during the aGtive period of congestion by 
recourse to blood-letting, it must be on some other ground than that 
of lightening the load which is said to oppress the organs ; and if 
we wish and hope to relieve the nervous system by this abstraction, 
it must be on some other theory than that which supposes a sedative 
and deleterious property to be possessed by the venous blood. In fact, 
if we trace the series of morbid phenomena we shall find that the cir- 
j culation becomes gradually weaker and deranged by the increasing 
inability of the heart and capillaries to perform their respective func- 
tions — an inability which is dependent on the irritation and depres- 
sion of the nervous system, and which becomes in its turn a cause, 
but is not as erroneously supposed an effect of the congestion. 
I Were it otherwise, the paroxysm could never be recovered from 
without the removal, by blood-letting, of some of the load which op- 
presses the heart, brain, lungs, and other important organs ; whereas, 
we know how often the reaction takes place with precisely the same 
load on the organs as before. And, again ; if there are two orders 
1 of organs to be acted on by our remedies in times of great moment 
! and danger, we ought surely to direct our measures to that one which 
i is most susceptible of impression and which most readily transmits 
i its impressions to the others. In the present case, there can be no 
question which of the two orders, that of the nervous system or 
the circulatory, manifests most early and distinctly the desired 

50 



582 



CONGESTIVE FEVER. 



susceptibility. But, whilst admitting this fact, it may be argued that, 
some how or other, we can influence in a remarkable manner the 
nervous system by diminishing the quantity of blood in the vascular 
system. In cases, for example, of apoplexy, meningitis, and cere- \ 
britis, blood-letting is the best and sometimes the only effectual 
remedy. I may even now be reminded of the statement which I 
made in a former lecture, that there is an antagonism between the 
vascular and nervous systems, and that by diminishing the func- 
tional activity of one of them we give opportunity to a wider 
and more diversified display of the other. In the case before 
us it will be alleged that the nervous system more speedily reacts 
after blood-letting ; and the experience of Mackintosh and others 
will be cited in practical proof of the efficacy of the operation in the 
very stage of congestion now under notice. Facts are ever the 
best, as they ought to be the only foundation for philosophy and 
philosophical theories ; but it is ve°ry difficult to reach the appli- 
cation until the facts are in such number and connexion as to 
prevent our being puzzled by what are called counter facts, or 
occurrences, in which the premises were supposed to be entirely 
identical with those of the first series, but the termination of which, 
the same agency intervening as in the first, is quite different. I say 
supposed ; of course there is not the identity in fact. Thus, in oppo- 
sition to the practice of Mackintosh is the experience of many phy- 
sicians in the congestive fevers, both of the autumnal and winter 
constitutions. I will just quote the observations on this point of a 
writer whose stimulating treatment of the cold stage I have already 
referred to. Dr. Wm. J. Johnson, the gentleman in question, lays 
down the first indication of cure to be — " to restore the lost balance 
of the circulation," — and the first part of the plan of treatment pur- 
sued in accordance with this indication, was " to open a large orifice 
in each arm, and if the blood will flow at all, to bleed the patient ad 
deliquium ; but," and the confession is an important one, "it is 
seldom, perhaps not once in fifty cases, that the surgeon can be 
successful enough to obtain blood." Here is one great objection, on 
the score of time, against attempting venesection, which commonly, j 
if not necessarily, will prevent, for a while, the adoption of other j 
measures for resuscitation. But of the effect of the loss of blood, 
when it is procured, we can form some opinion from the cases 
given by Dr. Johnson in the article already quoted. In two 
out of the five fatal cases which he records, both venesection and 
cupping were practised. One of these, a negro girl, aged nineteen, 
and who was subject to rheumatism, was seized with the fever after 
getting wet. Dr. Johnson was called in, and found her labouring 
under all the symptoms of congestive fever. The details of the 
treatment, which he at once adopted, will be told in his own 
w J ords : 

" I bled her from the arm ; applied some cups to the spine, made use of frictions 
over the spine with hot turpentine, oiJ, and capsicum; applied sinapisms to the 
inside of the thighs, and a blister plaster round the rheumatic joint : ordered the \ 



VENESECTION IN COMATOSE FEVER] 



583 



warm bath, enemata, and cathartic medicines. Under this plan of treatment she 
seemed to grow better ; became sensible ; spoke rationally, and to all appearance 
j was out of danger. I advised the use of spiritus Mindereri in hot teas, and left her, 
thinking the next day to find her better; but, unfortunately, I laboured under a 
| false delusion. I found the girl much worse than ever, and in fact she died not 
many hours afterwards." 

The other case was of a boy at school, 14 years of age, who, in the midst of ap- 
parent good health, was seized with congestive fever in such a degree that he was 
thought to be dying. Dr. Johnson narrates the treatment': — " I bled him, and gave 
j him an emetic of tartarised antimony. He threw some putrid, half digested sub- 
j stance from his stomach, which I" found on examination to be chestnuts. He was 
j insensible to venesection and to the operation of an emetic. I then cupped him ; 
| and applied sinapisms to his extremities, and a blister over the cervical vertebrae. 
| He still continued to be collapsed, and I endeavoured to force down him a bowl of 
| hot negus, with other stimulants, but was unable to do it. I then called in Dr. 
] Brown, and we determined on giving him calomel, as usual in such cases, together 
I with enemas, cupping aud stimulants. By persevering in this plan of treatment 
we succeeded in opening his bowels and unloading them of a large quantity of dark, 
j offensive, vitiated bile. After this he became sensible, and expressed himself 
| better. There was a pretty considerable excitement in the arterial system, and 
we treated him for several days on the depletory and evacuant plan. His friends 
j entertained the strongest hopes of his recovery, when on a sudden he complained 
j of acute pain in his head — went delirious, and seemed for a time to be labouring 
l under an attack of phrenitis. These symptoms were attended with convulsions 
| and othernervous symptoms. Blisters were reapplied to the head and behind the 
I ear; but, notwithstanding this, he went into a fatal state of collapse, from which he 
never recovered. The pupils of his eyes were widely dilated and insensible to 
the stimulus of light; picking at the bed-clothes ; low, muttering delirium ; inco- 
herent speech ; suhsulLus tendinum ; involuntary evacuations, — were the symptoms 
which closed the scene." 

The history of the above case, like that of every other which I 
have seen in our journals, is incomplete, — in no mention being made 
of the hour of invasion of the fever, nor of the accession, if there 
was any, and the symptoms each day. We are left in ignorance 
of the entire duration of the fever, and of the day and hour when 
the paroxysm, marked by acute pain in the head, &c, came on; 
and of the interval between it and the supervention of final " col- 
lapse." We are of course left to conjecture that this case may 
have been a malignant double tertian. It is natural for every 
! physician of thought and right feeling to review the course of 
treatment which has been pursued unsuccessfully, either in the case 
of his own patient or that of a professional friend, in the hope that 
some hint for his better guidance may be suggested by the inquiry. 
Hence, it is no impeachment of Dr. Johnson's skill for me to ask 
whether, in limine, the idea of a fever going through a series of 
stages, and of a definite period before its crisis is reached, would not 
have been of service in the regulation of the treatment, and served to 
I restrict somewhat the range and boldness of that which is called the 
| " dashing" or " heroic" practice. Next, what would have been the 
i effect of mild external friction and warmth, and the administration 
i of an enema of laudanum during the first stage, or that of depression. 
Reaction after this would be a fairer measure of the powers of the 
system, and might be met by the lancet, or by a mild emetic if the 
stomach were much oppressed, and calomel and its adjuncts to clear 



5S4 



CONGESTIVE FEVER. 



the bowels. But, remembering the strong probability of the fever 
being of the periodical class and of the recurrence of a paroxysm 
similar to the first, quinine would suggest itself to the medical at- 
tendant as a remedy calculated to prevent this dreaded occur- 
rence. 

The reaction which follows venesection in cases of extreme de- 
pression in the cold stage of congestive fever, is indeed a sequence, 
but not so often, if at all, an effect of the operation, as is commonly 
supposed. — It is an evidence of recuperative powers of the nervous 
and other systems which were merely suspended or perverted in 
their manifestations : but it does not depend on venesection for 
its occurrence. When we row with the tide our boat goes bravely 
onwards, and we regard with complacency the effects of our 
strength and skill in the use of the oars : but let the tide be adverse, 
and the same strength and skill which were thought equal to my 
emergency of this nature are not enough to give our boat head- 
way. So it is with bleeding: if there is vitality enough and the 
circle of action tends to revival, we congratulate ourselves on what 
we have accomplished by the use of the lancet; but if the tendency 
is the other way, or towards an extinction of the powers of life, 
our boasted instrument will be of no service in aiding us to prevent 
the fatal termination. In the case last cited of Dr. Wm. J. Johnson, 
the patient remained as senseless after the operation as he had been 
before it. 

Whilst I have little faith in the efficacy of venesection for the re- 
moval of congestion merely, I would not deny the utility, and often 
the necessity of this operation in cases in which there is inflamma- 
tion associated with fever. That this is a common occurrence we 
have every reason to believe, as well after an attentive study of 
the symptoms as of the appearances of the organs revealed by 
post mortem examinations. So soon, therefore, as febrile reaction is 
fairly established, or there are symptoms of its having begun, and we 
find evidences of more than high nervous irritation of an organ or 
organs, our endeavour should be to arrest their supposed phlogosis 
by blood-letting. If opium have been previously administered, in 
the manner and for the purposes indicated in my last lecture, the 
reaction will be of a simple nature; and as the nervous symptoms 
will have been removed or suspended by this medicine, the distress 
which remains may fairly be attributed to another or an inflam- 
matory condition of tissue or of organs. In common, however, we 
cannot expect that full and entire expansive reaction so usual in 
the phlegmasia? and in the exacerbation of regular intermittent and 
remittent fevers. Still, the vascular system is measurably brought 
into activity in conjunction with the nervous, and we are required 
to shape our measures in such a way as to act in and relieve both, 
and in the belief, also, that we have inflammation to combat. The 
manner in which blood is to be abstracted as well as its amount are 
matters of weighty consideration. If the operation is intended to 
be tentative, and as a means of trying the extent of the latent 



LOCAL BLOOD-LETTING. 



585 



I powers of the system and its capability of reaction, a small bleeding 
| is to be first practised ; and the safer mode of doing so will be by 
cupping or leeching. More especially is this selection to be insisted 
on if the circulation is yet sluggish, the chylopoietic viscera are 
congested, and the torpor of the cold stage measurably remains. 
I By cupping or leeching the abdomen, we not only abstract 
! blood from the circulation, and thus relieve the suffering organ as 
1 we would by venesection, but we give the heart more time to ac- 
I commodate itself to the altered quantity of blood than after a large 
! vein is opened ; at the same time that we procure the benefits of revul- 
sion or counter-irritation, in making the scarified or leech openings 
on the skin so many points of afflux; in fine, there ensues temporary ex- 
ternal congestion which we oppose to the more enduring internal con- 
gestion. But let us not commit the mistake, and it is no uncommon 
! one, of supposing that we leave the heart and general circulatory 
apparatus in a different state from that which would have been 
; caused by venesection ; in other words, as the common phrase is, we 
do not weaken the system so much by local as by general blood- 
letting. We probably shall not bring on syncope or the sudden 
feeling of weakness so soon by cups or leeches as by the lancet ; 
| but the secondary effects, those which will be evident a few hours 
after the operation, are identical: and hence, if our patient cannot 
spare a reduction of the amount of blood in his vascular system 
he cannot spare it by cupping or leeching. This proposition relates 
to the abstraction of blood merely, and without reference to the 
revulsion accomplished by local blood-letting, which sometimes 
is, to the full, as powerful in bringing about a beneficial change as the 
loss of blood itself. If, then, we have in our own mind solved the 
problem of the propriety and necessity, and they ought, in the prac- 
tice of medicine to be nearly convertible terms, of blood-letting, and 
we wish to procure as great a change as possible in the circulatory 
apparatus, and organic and functional movements of the organs 
generally, we shall have recourse to topical depletion by the aid of 
scarifiers and cups or of leeches. The comparative advantages 
of these two last methods stand thus: the more completeness and 
greater duration of the revulsion by leeches is balanced by the 
uncertainty of their taking the desired quantity, owing to their 
smallness or weakness and sickness, and the occasionally subsequent 
inconveniences and positive injury from the difficulty of stopping 
the flow of blood from the orifices made by their bites. In coun- 
try practice, blood-letting by cupping and scarifying is preferable, 
as the physician is his own operator, and knows precisely, or with 
sufficient accuracy, the quantity of blood which he takes away; nor 
will he be afraid of being sent for to a distance and at unseasonable hours 
to stop a bleeding which has perhaps continued for a length of time after 
the removal of leeches. Simpler methods failing, lint dipped in a min- 
eral acid and pressed with the head of a pin or a bodkin against the 
orifice, or lunar caustic scraped to a point and pressed for a few seconds 

50* 



CONGESTIVE FEVER. 



on the part, or a knitting needle at a white heat similarly applied, i 
will arrest the hemorrhage. 

Under circumstances of depression and congestion, in which it is J 
desirable to obtain revulsion without loss of blood, dry cupping i 
will be found advantageous. The remedy has antiquity, and, what j 
is still better, very decided practical testimony in its favour. Not 
only is dry cupping a revulsive in reference to the vascular system, 
but it is a counter-irritant and perturbating remedy to the nervous, 
and it will doubtless contribute to shorten the period of concentrated ; 
irritation in the first stage of congestive fever. It is not neces- ! 
sary to cause much pain by the application of the cups, either by 
a great vacuum or by their number ; nor, in the disease before us, 
should they be put on the abdomen alone, but also on the shoulders, 
legs, and arms. Dry cupping will be a prelude to cups and j 
scarification, if, after the first, we discover incipient reaction, and 
yet believe in the necessity of the abstraction of the blood. In 
affinity with local blood-letting at this time is opium, which will 1 
contribute powerfully to the expansive action begun by the first 
remedy. 

Should you be prevented from recourse to leeches or to cupping, 
in the case, the best substitute is venesection, so practised that only 
a small quantity of blood flowing from a small orifice shall be 
taken at once. This kind of practice was a favourite one with 
the physicians of the last century who had congestive fevers 
and inflammation marked by congestion to treat. It has been 
commonly called the Riverian, after the distinguished physician 
who gave it most vogue. 

In whatever manner blood has been withdrawn the physician 
expects to see a mitigation of the most urgent symptoms of the j 
oppression, which, as we are commonly told, was caused by the con- 
gestion, but which, in fact, is one of its concomitants. A common \ 
test, apart from this effect, of the propriety of the measure, is a reac- j 
tion, as it has been termed, a developed in place of suppressed excite- ' 
ment, in which we find the pulse fuller and sometimes stronger, the j 
heat of the body more diffused, and the freedom of function generally. I 
even that of muscular motion, greater than before. But there is no 1 
little fallacy on the subject of the reaction of the system under bleed- 
ing, purging, &c. Nothing is more common, even in hysteric women, 
than a kind of reaction after loss of blood ; the pulse even may be fuller 
in consequence. We shall find, also, an aggravation of some 
symptoms, as of headache and other pains, restlessness, wakeful- 
ness, flushing of the face, and dry skin, and other symptoms com- 
mon in fever, and which sometimes have been regarded as a reason 
for repetition of the blood-letting. This opinion is the more likely 
to be entertained if the symptoms still persist ; and the physician 
then thinks he has evidence both of the obstinacy of the disease 
and of the propriety of the steps which he has taken for its removal. 
A medical man will be slow to blame himself for frequent blood- 
letting, so long as symptoms which in his mind evince inflammation 



I 



ALLEGED REACTION AFTER DEPLETION. 



587 



continue : but when he learns that these are results of nervous 
disorder, and that they are aggravated by the loss of blood, he 
will attach a different meaning to the phenomena of reaction from 
that which influenced him at first. Blood-letting does not act 
merely as anevacuant, nor a sedative ; but it is a means of causing 
a new action and new movements in the functions and propor- 
tions of the organic elements. It is often perturbating, even when 
its effect, by the abatement or removal of inflammation and in 
other cases of simply strong febrile excitement, is most obvious. The 
commotions and agitations which it causes are such as to give 
rise to most opposite opinions on the subject. Some mere matter- 
of-fact persons, intent on an observation of general results alone, 
and without trying analysis or protracted causation, allege, that 
their patient is worse by the blood-letting, and they will not 
repeat it. Others, taking the reaction and its concomitant agitations 
as evidences of restored vital energies, and even of more developed 
morbid excitement, think that they see in these symptoms a proof, 
not only of the propriety of the first venesection, but a necessity for 
its repetition. There are others again who, like Armstrong, re- 
gard the reaction as a necessary, but not desirable result of blood- 
letting, and who prescribe a full dose of opium to moderate it. 
Upon the whole, you will discover that it is not so much the amount 
of febrile reaction that is to govern you in first recourse to vene- 
section or in its repetition, as the condition of the organ or 
organs whose derangement of function and morbid sympathies 
induce a belief that they are inflamed or are the seat of a perma- 
nent congestion. If you do not choose to moderate the force of 
the reaction by the administration of opium in the manner recom- 
mended by Armstrong, you ought, at least, to allow a reasonable 
period for its subsidence, since, like other organic actions, it requires 
a determinate time for its completion. If, for instance, after having 
bled your patient in the morning you meet with what are called 
symptoms of strong reaction in the afternoon, this ought not to be 
received in proof of a really developed morbid excitement, or of 
greater energy in the system than was anticipated. The proba- 
bility is, that the pulse, which you find at this time full and perhaps 
bounding, will by midnight begin to fall in force and frequency, and 
by the next morning will be lower than it was before the venesection 
of the preceding day. 

But of the real quality and cause of this reaction after blood- 
letting, and of its duration, we can have only very imperfect ideas, 
so long as there is foreign and irritating matter or undigested re- 
mains in the stomach and small intestines, and fecal accumulations 
in the large. Even if these matters were not the primary cause of 
the fever, they become, in the state of altered sensibility and organic 
action of the gastro-enteric mucous membrane, a cause of irritation 
and of aggravation of the original ills. To the means therefore for 
their removal ought we now to direct our attention. Cognisant as 
we are of the diversified sympathies of the colon with the rest of 



588 



CONGESTIVE FEVER. 



the abdominal organs, and of the great relief to oppressed respira- 
tion and circulation brought about by an evacuation of its contents, 
one of the very first steps in the treatment of congestive fever must 
be the administration of a purgative enema, and its repetition until a 
free operation is procured. As the digestive mucous surface is in 
a state of active irritation in this fever, and is inflamed in places, 
we can use agents of more reduced power than those which at first 
would seem to be required by the depression of the system. Simple 
tepid water, or salt and water of the same temperature, thrown up in 
full quantity and at short intervals until there are free evacuations of 
fecal matter, will often suffice. In more torpid states of the system 
spirits of turpentine in a dose of half an ounce, mixed with castor 
oil or common suet and mucilage, has an excellent effect. After 
the full operation of these enemata, if the internal abdominal heat still 
persists and the skin and extremities are cold, simple injections of cold 
water will greatly contribute to equalize temperature and vascular 
and nervous excitement. The retention of the fluid in the colon 
tends to allay heat and thirst, and by its absorption will probably 
exert a salutary operation on the blood. If there be too great a 
crasis of this vital fluid, and slowness of circulation, a minute quantity 
of common salt in the water will enable us to meet the indication 
furnished by this state of things. But if the torpor continues after 
the first* free evacuation of the lower bowels, it will be advisable 
to try the opium practice at once, by your giving an enema of laud- 
anum, or sulphate of morphia, in the manner already prescribed. 
This course procures, in addition to the advantages before detailed, 
tranquillity of the stomach, and prevents an excuse for the admi- 
nistration of various effervescent and other draughts intended to 
allay its irritability and to check vomiting, but which in fact are 
themselves troublesome irritants, and fail to accomplish the ends 
proposed. 

Should there be, from the beginning, nausea and imperfect vomit- 
ing of glairy mucosities and of particles of undigested food, it will be 
your duty to make the expulsive efforts more complete by the 
administration of a few grains of ipecacuanha, and subsequently of 
tepid water or warm chamomile tea. Not only will the stomach- 
be freed from irritating matter by this means, but the entire nervous- 
system of organic life will be roused to a series of efforts which will 
tend greatly to substitute expansion for morbid concentration, and to 
incite the secretors, mucous and glandular, to a fuller and more 
harmonious effort. But it must be remembered, that the general 
perturbation, the sickness, nausea, and depression, which precede 
vomiting, and the increased capillary action and secretions, including 
perspiration, which accompany and follow the act itself, simulate a 
paroxysm of fever, and like it require a regular period for its pro- 
gress and completion. The administration of an emetic is not, 
therefore, a mere incident, which is to be hurried through as rapidly 
as possible, in order to pour down enormous doses of calomel, or, 
worse again, drastic purgatives, or to bleed, blister, &c. Time, 



DRY CUPPING, PURGATIVES. 



589 



! as I have said, is required for the series of effects which follow to 
be completed ; and it is only after their completion that you can 
take proper cognisance of the condition of the system, and of the 
necessity which exists for other measures, ,or for allowing rest. 
An emetic will precede the use of the lancet, or local depletion, 
where the gastric distress is the predominant symptom, and the 

! depression of the nervous system and concomitant congestion, 

1 with rigors, cold extremities, &c, w 7 ell marked ; or it may 
establish such relations among the organs as to render blood-let- 

1 ting unnecessary. 

In cases of extreme concentration of vital action, dry cupping and 

! emetics will be consistent practice; a little more action, and a belief 

| that the internal viscera are suffering from inflammation, will recom- 
mend scarification and cupping, or leeches, with an emetic. The 
lower bowels having been freely emptied, and the stomach still 
distressed with nausea and imperfect vomiting, this latter remedy will 

j also come into requisition. Failing to give a vomit, and the lower 
bowels not having been acted on by an enema ; or even if after the ope- 
ration of these remedies there is a feeling of w 7 eight and oppression, or 
of distention with flatulency of the bow r els, or of deep sickness which 
does not amount to nausea, — pain in the back and near the 
kidneys, — and pain or want of natural sensation in the lower limbs,, 
you will not hesitate to give a purgative. But the selection on 
this occasion of a suitable one is not by any means a matter of 
indifference. We may not, perhaps, be deterred from purging by a 
knowledge or a strong and well-founded belief of there being 
gastro-enteritis in the case before us, but we certainly ought to 
procure the effect with as little irritation as possible. With this view, 
and still holding in most respectful remembrance the denunciation of 
Broussais against purgatives of any kind in such a state of things, 
I have no hesitation in recommending calomel in doses of ten 
to fifteen grains, to be followed after the lapse of a few hours by 
castor oil and spirits of turpentine — half an ounce of each mixed with 
a little peppermint water and sugar ; or if the stomach be very 
irritable, and the case urgent, the spirits of turpentine alone may be 
given. Turpentine, though a stimulant both to the digestive and 
urinary organs, is in kindlier relation with inflamed mucous mem- 
branes than most medicines of the purgative class. In the choleric 
symptoms of congestive fever, a calomel pill of ten grains and 
the turpentine in a half ounce dose after a moderate interval, will 
be of marked service, and in some cases will precede other remedies, 
unless an emetic as already specified. 

Hitherto I have spoken of the several means which, in part or 
in whole, in succession or alternation, are adapted to the first stage 
of congestive fever, and more particularly to that of primary 
depression or temporary suppression of function, accompanied 
by concentrated nervous irritation. The period of common febrile 
reaction being reached, the treatment is not materially different 
from that which is adopted in the exacerbation of remittent fever. 



590 CONGESTIVE FEVER. 

It will of course be modified in adaptation not only to the violence j 
of existing symptoms, but to precursory treatment. Thus, if the 1 
reaction from primary depression and chill has been spontaneous, ,1 
or without the aid of medicines, or has been assisted by dry cup- 
ping and enemata, or by an emetic ; and if you find evidence of i 
inflammation of an organ, and something more than mere febrile J 
excitement caused by an expansive effort of the nervous system, you | 
will bleed, and to such an extent as to produce an impression on ; 
the system — a suspension at any rate of the violence of the pain and 
accompanying morbid symptoms — whether this result is attained 
by the abstraction of six or of sixteen or more ounces of blood. 
But it must ever be remembered, that the natural tendency of a 
disease of a periodical type is to remit, after the series of organic 
actions which constitute the paroxysm have been gone through. 
Sometimes it happens in the worst form of intermittents in hot 
countries, as Lempriere tells us was the case with those of Jamaica, 
that the chill is very short and the hot stage is exceedingly violent, 
often accompanied by delirium ; and that, after lasting from twelve to 
sixteen hours, it leaves, finally, the patient in a state of extreme and 
alarming debility. Now, in a case like this, unless there were evident 
complication of phlegmasia of an important organ, it would not 
seem wise to try to abate the violence of the paroxysm by blood- 
letting; and if we have recourse to the remedy, preference ought to 
be given to topical depletion. It is on such occasions that cold 
affusion, or at least a sponging of the surface with cold water, is 
both soothing and useful. Contributing to the same end, are the 
administration of cold water enemata and the use of cold water 
for drink, or of a small piece of ice allowed gradually to 
dissolve in the mouth. If acid be agreeable to -the patient, or a I 
slight bitter, the water may be flavoured accordingly; the only j 
restriction being on the score of the quantity of the fluid, which J 
ought not be so great as to distend the stomach, and in this way 
prove a source of irritation. There is hardly a medicine which • 
can be given during this last stage without irritating the stomach 
and increasing the general restlessness, unless, indeed, it be opium, 
and it only when we are sure of the ascendancy of irritation of 1 
the nervous system. Purgatives certainly should be abstained from 
at this time ; and most of the febrifuges, so called, are more than j 
equivocally hurtful. Some of the saline preparations might advan- I 
tageously insinuate themselves into the mucous absorbents, and 
enter the circulation with the aid of a liberal supply of a watery 
vehicle in the way just mentioned. The neutral mixture, the 
acetate of potassa, sesquicarbonate of soda and nitre, might be given 
in this way ; but, I repeat it, rather as part of the drink of the patient, 
of course in large dilution, than in separate ancl at all strong doses. 
There is greater probability of a more perfect remission by these 
simple means and of an approach to a crisis, indicated by more 
copious perspiration and renal secretion, than if purgatives, calomel, i 
antimony, and nitre, had been given during the first period of febrile 



TREATMENT OF THE REMISSION. 



591 



exacerbation. Even the pet organ, the liver, will be more apt to 
recover from its irritative congestion, and secrete bile by this aque- 
ous and saline regimen, than if it had been appealed to by means 
of the alleged specific and never forgotten calomel. If this period 
of febrile excitement has been reached without evacuations 
from the stomach and bowels — and there are nausea and efforts to 
vomit, it will not be amiss, nor in contravention to the opinions 
which I advocate on this subject, to give a draught of tepid 
water, or one in which a table-spoonful of salt has been dissolved, 
in order to evacuate the stomach of its contents, and even to break 
the bad habit which it had acquired for some hours previously. With 
a similar view, the lower bowels might be emptied by a simple 
laxative enema, as of salt and water, molasses and lard and water, 
or gruel. 



LECTURE VII. 

Treatment of congestive fever concluded — A remission or intermission being established 
our main reliance is on quinine — Purgatives and blisters inefficient, sometimes in- 
jurious — Mode of action of quinine, — sedative — Large doses of quinine required at 
this time — Authorities and cases in favour of this practice. Calomel and tartar 
emetic. — Analysis of the operation of calomel : it is at first and mainly a sedative — as 
such acts on the secretions through the nervous and capillary systems.. It is adapted 
to diseases of high action and is injurious when assimilation is imperfect and its in- 
terruption dangerous, as in scrofula, consumption, scurvy. Is regarded by Annesly 
as an anti-periodic — Harmony between calomel and quinine, — Advantages from giving 
them in alternation — Tartar emetic, its febrifuge and anti-periodic properties. — Second- 
ary congestive fever. 

A remission - or intermission having been established, a question then 
arises, which requires prompt solution preparatory to decisive action, 
as to the measures by which this may be prolonged and the recur- 
rence of another febrile paroxysm prevented. He who, forgetting 
the violence of the first paroxysm and the manner in which the 
chill was ushered in, should now think his patient out of danger, 
and either leave him to himself, or recommend merely light or per- 
haps animal food, commits a perilous mistake, of which he will be 
painfully reminded on the supervention of the next, and it may be 
the fatal paroxysm. Nor will it be prudent, even if a continuation 
of active remedies be determined on, for you to rely on purgatives 
with a view of cleansing out the bowels and of restoring the 
secretions from them and the liver, or on blisters as counter- 
irritants, in order to prevent the coming of the next exacerba- 
tion. Purgatives in congestive fever, especially those of the saline 
class, often play us false, and bring on choleric, or serous, exhaust- 
ing discharges, followed soon by extreme and dangerous prostration 
and collapse. Blisters have little efficacy in preventing the recur- 
rence of irritation of the nervous system in periodical fevers, as I 
the more readily believe from personal and painful experience. I 
have had five blisters on my own person at one time without 



592 



CONGESTIVE FEVER. 



their preventing the return of a chill, although I had no reason to be- 
lieve that there was an inflammation of any organ at the time. What 
then remains to be done in the emergency before you? Appealing to an 
experience which extends through centuries, and is the result of the 
observations of many physicians in different countries, you will 
lose no time, after a remission is clearly evident, in giving quinine 
now, as a few years ago you would have given bark. But you will 
not be induced to give it as early and as freely as you ought, unless 
you regard its therapeutical agency in a different light from that in 
which it is ordinarily presented to us. If, as is commonly done, you 
look upon it as a tonic, you will wait for debility to furnish a 
requisition for its use : if as a stimulant, you will fear to admi- 
nister it in cases in which there is obvious excitement, or less evi- 
dent, but yet real phlogosis. Now, it is neither a tonic nor a stimu- 
lant; nor, although it sometimes arrests fever in the middle of its 
course, is it entitled to be called an antiphlogistic. The effects of 
bark on the animal economy are not identical with those of either 
bitters or astringents any more than its chief alkaloid principle, 
quinia or quinine, is identical with the alkaline principles of these 
latter, as far as they have been discovered. Unlike stimulants pro- 
per, it has little or no immediate action on the vascular system ; nor 
does it seem to modify nutritive life by action on the capillary tis- 
sue so much as tonics proper. If we would ascertain the real 
effects of bark or of quinine on the animal economy, we must do 
so by watching its operation on the nervous system ; and by the 
extent of its impression on this system can we measure its influence 
generally on the other organic systems and apparatus. If its effects 
extend to these, it is through the intervention of the nervous sys- 
tem ; and if it cure fever by preventing a return of a paroxysm, or 
by modifying organic acts in the midst even of one, it is in virtue 
of the peculiar manner with which it impresses this system. But 
if it be neither a tonic nor a stimulant, by what term shall we desig- 
nate its mode of action. Admitting that the pathology of congestive 
fever ofthe double tertian orremittentkind, which I haveendeavoured 
to explain, is correct, — and that the circle of morbid phenomena, 
on which the type and its peculiar character chiefly depend, 
originates in, as it is kept up by irritation of the nervous system, 
then ought bark, or its representative, quinine, which arrests and 
subdues this irritation, to be called a sedative. But it will be alleged, 
in reply, that in various conditions of exalted and perverted sensi- 
bility, this medicine displays no such sedative influence. As ap- 
plicable to the nervous system of animal life or the encephalo-spinal 
apparatus, the remark is just. But in fevers, particularly those of 
which I now speak, the irritation, the sustaining cause of the periodi- 
cal disturbances in the brain, spinal marrow, and their dependen- 
cies, radiates from the abdominal nervous system belonging to or- 
ganic life. Opium is capable of allaying this irritation and of 
bringing the paroxysm to a close, and on competent authority it 
may be added, of preventing its return; but opium exerts, indepen- 



QUININE IN THE REMISSION. 593 

elently of its effects on the nervous system, a strong action also on 
the capillaries : it is apt to cause narcotism and complicated symp- 
toms transcending the degree of simple sedation. Quinine limits 
its action very much to the nervous system, producing neither nar- 
cotism on the one hand nor vascular excitement on the other; but as 
near as may be a sedative operation, which, like all the sedations 
| caused by other medicines of the least mixed nature in this 
i respect, will, however, at times be blended with some unpleasant 
i sensations. Of these, a humming sound in the ears, slight deafness, 
! and a feeling of tightness or stricture across the breast, are the most 
I usual. 

In reference now to the case before us, one of congestive fever, 
l and the period of the disease, that of remission, you will give the 
quinine with the more freedom when you give it as a sedative, or a 
means, at any rate, if this term sounds exceptionable, of removing 
entirely the irritation which originated and kept up the paroxysm, 
and which, though now abated, still exists, and only waits for 
the completion of another diurnal circle to display itself with fresh 
violence. Viewed in this light, quinine is on the same line or at 
least is in harmony with the other means to which you had early 
recourse for either breaking the force of the first and forming stage of 
the exacerbation, or for abating its violence in its progress onto remis- 
sion. The operation of quinine is not antagonist to that of blood-let- 
ting, nor is it congenial with inflammation. In so far as it acts on the 
nervous system by altering the susceptibility, we may say diminishing 
the irritability of this system, it influences the condition oftheinflamecj 
organ — stomach, intestines, or brain. Already I have shown how, 
indirectly but yet positively, the expansive reaction of the nervous 
system, by giving increased activity to the capillaries and blood- 
vessels at large, aggravates inflammation : and it is now easily seen 
how far a remedy, which alters the state of action of this system, 
and prevents the morbidly periodical expansive reaction and its 
precursor morbid concentration, will exert a beneficial tendency in 
repressing inflammation. It would be incorrect to call quinine, 
which displays this power, an antiphlogistic ; but assuredly of the 
two epithets it merits this more than that of stimulant. Let us, 
however, guard against extremes of opinion. Quinine prevents the 
recurrence of the paroxysm, and with it all those often truly alarm- 
ing, as to the patients they are distressing, complications, which 
I have so fully described to you; but it will not subdue the organic 
changes of tissue which constitute inflammation. This, ow 7 ing 
to the altered susceptibility of the nervous system, will be less felt, 
less marked by diversified sympathies, but still it remains ; and it must 
be carried off" by other means than quinine. 

The urgent demand, at the cessation of the first paroxysm of 
congestive fever of the double tertian type, is for means to prevent a 
second one. Even a marked diminution of the febrile phenomena, and 
particularly of associated inflammation, procured by blood-letting, 
will often warrant us in giving quinine. So long as we were swayed 

51 



594 CONGESTIVE FEVER. 

by the belief of its being a general stimulant, or a tonic opposed to 
asthenia, we were naturally timid in regard to the dose, and 
prone to withhold its repetition on the reappearance of the slightest 
febrile phenomena. It is true that, at different times, physicians of 
observation discovered that not only large doses of bark were to- 
lerated in slight remissions, and even in the hot stage of the fever, 
or in those mixed states compounded of nervous irritation and in- 
flammation, but that they were decidedly serviceable. Still the cases 
which they saw and recorded were thought to be exceptions to a 
general rule, and at most only to be met with in the fevers of tropical 
climates. But, when we speak of congestive fevers we mean those of 
the imperfect and complicated intermittents and remittents, which 
sometimes become continued remittents or sub-continued fevers, 
and which are chiefly met with in warm climates, such as in the I 
southern and western regions of our own country. To these 
diseases the remarks and experience of physicians who have prac- 
tised in southern latitudes in other parts of the world will be found 
to be strictly applicable, both in the early use of the bark and the 
magnitude of its doses. I shall not stop here to discuss formally the 
oft debated question of the probable share which the bark or 
its equivalent principle has in the keeping up and aggravating 
visceral congestions. The reasoning which I entered into, on the 
effects of this medicine in modifying inflammation, is applicable 
throughout to congestion; its prevention and indirectly curative 
power in both these states of disease is, I think, clear. It is also on 
evidence that there is no inconvenience or disorder attributed to 
bark or quinine, whether it be gastritis, enlargement of the liver 
and spleen, jaundice, dropsy, &c, which is not of frequent occur- 
rence anterior to the administration of the medicine, and which is 
often not worse after its use; and also, that all these visceral derange- 
ments have been severally met with in every degree, in cases in ; 
which no preparation of bark whatever had been prescribed. I 
will acknowledge, that in some cases of congestive fever, which, 
during two or three years, was not uncommon in the vicinity and j 
even suburbs of this city, I have given quinine and other prepara- 
tions of bark on the first appearance of remission without advan- 
tage, and, as it seemed to me at the time, with the effect of aggra- 
vating some of the symptoms — such as agitation, dry and furred 
tongue, morbid heat, dryness of the skin and increase of 
gastritis. But I cannot forget that in other cases, in which 
neither quinine nor its equivalent was given, I encountered 
a similar renewal of unpleasant symptoms and exacerbation of 
the fever; leading to a fair inference, that the quinine simply did 
not prevent the march of the fever and its recurring symptoms in 
the instance first mentioned. There were cases, again, in 
which, from a persuasion, shared by my seniors and colleagues 
at the time, that bark or quinine was inadmissible, the fever 
was allowed to acquire such fearful violence, despite of blood-let- 
ting, general and local, mercurials, opiates and blisters, that 
the double tertian type was merged in an obscure sub-continued 



SEDATIVE OPERATION OF QUININE. " 595 



one, and in this state of imperfect congestive reaction with stupor 
the patient expired. Of this nature was the case of a gentleman, 
whose servant was the subject of the comatose form of intermittent 
fever which I have already described in my addition to Dr. Stokes's 
lecture on that disease. This gentleman, after the first few days of 
fever, had a violent paroxysm every morning between six and seven 
o'clock — the predominant symptom of which was excessive gastric 
pain, together with coldness of the extremities and some rigors, 
followed by general but not full febrile reaction, and which did not end 
in any clear remission. Probably there was a lull after midnight and 
between that and the supervention of the morning paroxysm. The 
patient died with all the symptoms of cerebral congestion — the abdo- 
men having been tumid, hot, and tender on pressure; and the skin 
deeply discoloured with a muddy-yellow hue. 

Recurring now to the original proposition, that in the first clear 
remission of congestive fever, whether this be on the second, or, 
what is more probable, on the third day of the disease, counting 
that on which the first paroxysm appeared as the first day, you 
ought to have recourse to quinine, the next points to be ascer- 
tained are the dose and frequency of repetition of the medicine. If 
you believe it to act on the vascular and nervous systems con- 
jointly, as a general stimulant or even as a tonic, you will of course 
give it not only timidly but in small and, as we might call it, 
tentative doses,— fearful of lighting up inflammation, or febrile excite- 
ment dependent on or associated with inflammation. But if you 
regard it as a sedative, or at least as an agent capable of quieting the 
morbid irritation of the nervous system, by w 7 hich latter state the 
morbid phenomena are mainly produced; and if you bear in mind 
at the same time the toleration of the nervous system, when excited 
or irritated, to large doses of medicines, whose operation is more 
particularly spent on it, you will have no hesitation in giving full 
doses of quinine or their equivalent amount of bark. And in 
doing so you will act consistently with the view of the pathology 
of the fever which I have laid down, and of the therapeutical 
action of quinine ; and also with analogy derived from the effects 
of sedatives, generally, in full doses. When our object is to quiet the 
nervous system, to bring it completely and universally under a 
sedative and homogeneous influence, we give a large dose of 
opium : small ones we know have an unequal and occasionally 
disturbing, if not actually exciting, effect. Such, we have good 
reason to believe, is the case with quinine. A large dose acts at once, 
or very soon, on the nervous system ; and by diffusing the sedative 
influence throughout all its parts it completely allays irritation, and 
induces general tranquillity of the functions ; excepting always in 
as much as they may continue to be disturbed by the phlogosis of 
some organ — stomach, brain, and its meninges, or by the persistent 
congestion of the spleen and liver. 

Before referring to the experience of the numerous writers 
who have prescribed the bark, and of those who have employed 



596 



CONGESTIVE FEVER. 



quinine, or, more correctly, the sulphate of quinine, we ought first 
to be persuaded that this chief alkaloid principle of the bark, or its 
saline combination, has the same virtue with the bark itself; and, 
secondly, to have ascertained the proportional amount of the quinine 
in the bark. On the first point I cannot now enter into detail, nor is 
it necessary, as I must suppose you to know that the bark consists 
of numerous proximate principles, of which the quinine is but one ; 
and that, therefore, the effects of the two articles cannot be identical. 
But you have also learned that the most active and chief sanitary 
principle of the bark is quinine ; and that by the readiness with 
which the latter is administered and retained in the stomach, and 
acts on the gastro-intestinal mucous surface, and thence, by sym- 
pathy and absorption, on all the other organs, it fully makes up for the 
diversified effects which might ensue from the bark in substance. 
Then there is the difficulty of the patient's swallowing and re- 
taining this last, and the slowness of its action — composed, as 
much of it is, of ligneous and inert matter — on the digestive mucous 
surface and other organs. In reference to the second point, which is 
one of pure pharmacy, the results of various experiments by different 
individuals are not by any means uniform. Not to occupy your 
time with details, it will be sufficient for me to say, that the average 
of the products obtained by different practical chemists — M. Henry, 
MM.Pelletierand Caventou of Paris, and M. Tilloy of Dijon — would 
show rather more than eight grains of sulphate of quinine in an ounce 
of bark : the lowest, that by M. Henry, being five grains and a half; 
and the highest, that by Pelletier and Caventou, a little more 
than eleven grains ; and the middle quantity, that by M. Tilloy, 
nine grains in an ounce. When, therefore, we in this region 
gave from one grain to a grain and a half' of quinine at a 
dose, we deemed it equivalent to a drachm of bark, the medium 
dose of this article in periodical fevers. But during this time we 
were well aware that bark had been given, and we sometimes gave 
it ourselves in half-ounce doses. Patients from the tropical regions 
and physicians who practiced there had repeatedly spoken of an 
ounce taken at one dose. Consequently, when we increased the 
quantity of quinine to four, five, and even eight grains at a dose, 
we knew that we were not going beyond the limits of former 
practice elsewhere, and particularly in warm climates ; and there 
was this additional circumstance for encouragement in our pro- 
ceeding, that the stomach could not be as much oppressed by the 
salt of the bark, as by the large amount of it in substance ; and 
hence that ten grains of quinine at a dose was really less heroical 
practice than an ounce of the bark taken at once. 

If we are desirous of making an impression at all decided on the 
nervous system, and through its sedation of allaying the febrile dis- 
turbance of the functions generally, five grains of sulphate of quinine 
is the smallest dose which we should think of prescribing for an 
adult, whose idiosyncrasy is not such as to forbid the use of the 
medicine beyond minute doses. Nor should we rest content here : 



LARGE DOSES OF QUININE. 



597 



we ought to direct a repetition of the dose once or twice more, 
at an interval of two hours. The preferable mode of administra- 
tion, with a view to obtain its earliest effects, is in solution and in 
such a medium as will prove most palatable to the patient, and 
be most likely to insure its retention by the stomach. Contributing 
to the latter end, and harmonising well with the quinine, is a dose of 
about twenty-five drops of laudanum with camphor water ; and 
for the former, cinnamon water, or lemon or ginger syrup. When 
convinced of the propriety of the union of quinine and opium, a neater 
formula, and one in the administration of which there will be less 
liability of mistake by the nurse or other attendant, is a solution of 
the two sulphates, as follows : — R. Sulphat. quin. 9i., Aquae cam- 
.phor. ^ij., Sulphat morphise, gr. ss., Acid, sulphuric, gtt. vi. M. 
ft. solutio. Dose, a table-spoonful in any fluid most agreeable to 
the patient. You are, of course, aware that the sulphatejof quinine, 
as an imperfect salt, is not entirely soluble in water, and hence the 
addition of a few drops of sulphuric acid is necessary. 

In cases of more intensity, and in which it is of the utmost im- 
portance to produce a full and strong impression on the nervous 
system, so as to prevent, if possible, a renewal of the fever, or 
rather a recurrence of the paroxysm which might end fatally, a 
still larger dose of quinine is not only admissible but required. 
Dr. Bailly, on this point, says that physicians need not be under any 
apprehension from the effects of large doses of this medicine. " If 
fifteen grains, divided into three or four doses, suffice in common 
cases of intermittent fevers during the day of apyrexia, we must 
give twenty, thirty, forty grains, and even more than this, in a few 
hours, if we are in dread of the effects of a paroxysm, the first 
accession of which placed the patient in peril." In some of the 
cases in the hospital of San Spirito, you will have noticed that 
twenty grains of the sulphate of quinine were prescribed in the 
morning, and taken before the afternoon paroxysm. Dr. Bailly 
himself took a hundred grains of the sulphate of quinine in five days, 
for a slight febrile disorder, when he was at Rome ; and he 
declares, after an attentive analysis of his own feelings, that he 
was unable to detect any evidence of irritation, which this quantity 
of the medicine would certainly have produced if it had been of an 
irritating or stimulating nature. In one of the hospital cases 
recorded by this gentleman, he mentions seven ounces of bark to 
have been taken in one day by the patient, — which would be equal 
to nearly sixty grains of quinine. Dr. J. K. Mitchell, quite recently, 
in conversation on this subject, stated to me that he gave to a 
patient, who was in the last and apparently fatal stage of remittent 
fever, sixteen grains of quinine, and with such good effect, that 
from that time the violence of the disease was subdued and con- 
valescence soon established. He felt the more confidence in so 
large a dose, from having known a man to take in the course 
of a day, by a misapprehension of advice for the manner of 
using them, a box of pills consisting of sixty grains of quinine, 

51* 



598 CONGESTIVE FEVER. 

and with no other inconvenience than a singing in the ears. But 
let us avoid an inference, which is sometimes hastily and 
erroneously drawn from a knowledge of the toleration of the system 
to large doses of a medicine, that it has not the activity commonly 
attributed to it. Even if we were not apprised of the fact in 
various instances, one under Dr. Mitchell's own notice shows by 
how small a dose some persons are affected. His patient, an aged 
adult, cannot take an eighth of a grain without being troubled with a 
singing in the ears and other nervous symptoms. Still more 
decided testimony in favour of the efficacy of large or, as the writer 
calls them, mammoth doses of quinine, is borne by Dr. J. E. May, 
of Madison county, Alabama; {Transylvania Journal, vol. x.) 
who cites the corroborative experience of Dr. Thomas Fearn. 
Dr. May, on the occasion of his having been attacked with a 
quotidian remittent, the paroxysm of which came on about ten 
o'clock in the forenoon, and the remission at one or two at night, 
took on the fourth evening of his disease, ere the fever had yet left 
him, fifteen grains of quinine, which he repeated every two hours until 
a drachm had been thus used. He had himself copiously bled just 
before he began to take the quinine. The effects are thus narrated : 
"Instead of the usual remission I had a complete intermission. 
The fever left me while I was taking 15 gr. doses of quinine. I 
passed the day without the recurrence of the fever; was affected 
with some degree of stupor, ringing in my ears, and deafness; but 
with no other uncomfortable sensation. A dose of calomel taken 
about eight o'clock, forenoon, brought off evacuations of the con- 
sistence of black clotted blood. The quinine was continued for 
ten days, in smaller quantities, and my bowels kept open with 
calomel, rhubarb, and aloes, and my recovery was rapid." Dr. 
May states, that " when under the full and proper influence of 
quinine, healthy biliary secretions are readily set up, and by means, 
too, which under other circumstances had failed." In another 
case of fever " of a malignant character," of three weeks' duration, 
the patient was "in a state of extreme prostration ; pulse one hun- 
dred and eight in a minute, and exceedingly small and compressi- 
ble; copious watery discharges passing from his bowels six or seven 
times a day, as he lay, without the power to control them ; and 
by no means the least unfavourable symptoms were colliqua- 
tive sweats, parched lips, an utter inability to sleep which had 
lasted for several days, with delirium during the night." The quinine 
in two-grain doses had been administered, but it was thought to 
have produced irritation. "It was now concluded to give the 
quinine a trial in ten-grain doses ; his case being considered at best 
a desperate one. I," says Dr. May, " was entrusted with the admin- 
istering of the medicine, with liberty to increase the dose to fifteen 
grains if the first ten should not produce the effect anticipated. This 
was manifestly clone ; and I accordingly gave him fifteen grains 
in each of two succeeding doses, making in all forty grains in two 
hours," The effects were such, that in one hour after the patient 



LARGE DOSES OF QUININE. 



599 



i had taken the third portion his pulse was reduced to eighty-eight 
j in the minute, with a more than corresponding increase of volume. 
All the unfavourable symptoms in a great measure subsided. The 
patient slept several times during the evening, and had a better 
night than he had passed for many previous. A blue pill given at 
night, produced in the following morning fetid discharges ; and a 
favourable crisis in the case was manifest. On this day, three 
fifteen-grain doses were administered at intervals of an hour; he 
had no return of fever ; rested well at night ; a mercurial cathartic 
produced evidence that the proper secretions from the liver were 
•excited ; the patient was treated with smaller portions of quinine in 
the forenoon, and purgatives at night, for two or three days after; 
and in two weeks was up — " Cases are given of complication of 
pulmonary disorder with gastro-hepatic derangement and delirium 
sustained by intemperanee, and reducing the patient to the lowest 
state, but which were cured by large doses of quinine. Dr. May 
very properly remarks, in coincidence of opinion with the older 
writers already quoted, that when the affections of the chest "are 
evidently regulated by the remittent, aggravated in the exacerba- 
tion of the fever, and moderated in the remission, they may be set 
down as symptomatic, and so treated." Dr. Drake {Western Jour- 
nal, Vol. XL), after noticing Dr. May's paper, adds, — " We are 
pleased to meet with this new testimony to the safety and value of 
large doses of the sulphate. Dr. M. seems to regard them as with- 
out precedent, but in this he is mistaken ; at least ten years ago Dr. 
Perrine, of the state of Mississippi, administered this medicine in 
such quantities as to amount to a drachm in a single intermission, 
and we ourselves, for many years past, have been accustomed to 
give it in doses of ten or fifteen grains. We have also been in the 
habit of combining it with calomel, a practice which is general 
among the physicians of this quarter. Of the harmlessness of large 
doses we some time since had conclusive evidence* by being called 
to see a man the next day after he had, by mistake, taken a 
drachm at one portion. He still had a roaring in his ears, but was 
walking about the house, and had not experienced any formidable 
symptoms. They, who limit themselves to small doses at short 
intervals, are not aware how much, in many cases, they sacrifice 
to their timidity. To a patient who laboured under a neuralgic 
affection, apparently of miasmatic origin, we lately, in conjunction 
with a medical friend, administered a scruple daily for five or six 
weeks, without any other sinister effect than a noise in the head 
and a slight degree of deafness. Jt was given in five-grain doses, 
combined with ten grains of nitrate of potash." 

I have dwelt somewhat longer on this part of the treatment of 
congestive fever, because much of your success will depend upon 
the turn you give to the disease on the occasion of an early or the 
first remission, it may be intermission. You will see now a pleas- 
ing harmony between the pathology of the fever and the effects 
which quinine produces on it, and you will no longer be deterred by 



600 



CONGESTIVE FEVER. 



erroneous theory from a free and early exhibition of this valuable 
medicine. I will not attempt to trace the treatment to be pursued 
day by day should the fever not be subdued in its early period ; but 
would apprise you, that you must not expect a series of distinctly 
marked paroxysms and clear remissions in its progress : on the con- 
trary it will assume the sub-continued form, so that it will be dif- 
ficult to see any change from day to day in the symptoms. Closer 
observation, however, will enable you to discover an exacerbation 
at a particular hour, commonly in the day ; and a diminution of the 
violence of the symptoms, after an interval from this time usually be- 
tween evening and early morn, which is indicated by a slight moisture 
and lessened frequency of the pulse. This latter is the time which 
must be seized with avidity for the administration of quinine, 
in imitation of the practice of the older physicians, who began to 
give bark at the decline of a paroxysm and while there was 
even yet some fever; and without waiting for that which might never 
present itself — a perfect remission. 

There are two other medicines of great power, which are used 
in the increment of fever with a view to their febrifuge action, in- 
dependently of their direct effect on the alimentary canal : these 
are calomel and tartar emetic. By the theory of the American 
schools generally, calomel is recommended, after its first and purgative 
effects have been procured, as admirably calculated to promote 
the secretions and particularly the flow of bile, or to check them 
when redundant and to correct them when depraved. Often its 
use is persisted in, with a view to its producing other changes, 
which have obtained for it the vague and indefinite appellation of alte- 
rative, and which in their completion are supposed to be indicated by 
salivation. It would be foreign from my present plan to engage in 
a therapeutical disquisition on these several points, but I cannot 
pass the subject over so slightly as not to point out the hasty ob- 
servation and empirical practice of most of those who in various 
parts of our country prescribe calomel in fevers and the phlegmasia 
generally. It seems to me that both the purgative and sialagogue 
operations of the medicine, although they have been most insisted 
on, are but incidental effects, and not the chief and best ones that 
we might obtain by a more careful and judicious use of it. We 
hear of calomel stimulating the digestive canal and the secretory 
organs, and of giving rise after a time to mercurial fever ; and these, 
together with some other phenomena occasionally evidenced by its 
use, are adduced in proof of its being a stimulant or even irritant ; an 
opinion still further strengthened by the familiar fact of the difficulty 
of its exerting its specific effect on persons in whom the sthenic 
diathesis or high inflammatory excitement is met with. But, opposed 
to these hypotheses and facts, are the indications which seem so 
conclusively in many instances to justify its use. These are; great 
irritability and inflammation of the stomach, or of the stomach and 
small intestines conjoined — gastro-enteritis — a similar state of the 
lower bowels, as in bilious colic, dysentery, and acute diarrhoea ; bron- 



MODE OF ACTION OF CALOMEL. 



601 



chitis, hepatitis, violent inflammatory fevers — yellow and bilious. 
Then, again, in feeble frames, and in a scrofulous or lymphatic habit, 
in persons suffering from scurvy, or decided anosmia, and low fevers, 
calomel, which I speak of now to represent mercurial preparations in 
general, is by common consent contraindicated. What becomes 
then of the notion of the stimulating operation of calomel 1 A 
! somewhat careful observation of facts will show us that it is de- 
| cidedly sedative in its effects on the stomach and alimentary canal 
generally, and on the genito-urinary and pulmonary mucous mem- 
i brane. It will allay vomiting and gastric distress ; procure ease 
I and often sleep to the irritable and wakeful hypochondriac ; and 
: stop a harassing cough, the torments of repeated micturition, 
| and the heatand pain of gonorrhoea! and leucorrhceal discharges. But 
j the discharge, whether from the bowels or other cavities, is not 
; the cause of the relief afforded by the calomel or blue pill, since the 
latter effect is obtained before the former takes place. The same 
| remark applies to a restoration of secretions after these have been 
suspended ; the salutary change produced by the medicine is an- 
terior to the secretion, which last is truly a symptom and an effect. 
If mercury acts by stimulating the organs, we should expect to 
find its operation manifested in proportion to their asthenia, and 
to be contraindicated in all diseases of excitement. Experience, 
which makes it the auxiliary to the lancet, and associates it 
with tartar-emetic and salines, sufficiently rebuts such a notion. 
Repeating the language which I used many years ago on this topic, 
then incidentally touched on in my Account of the Doctrine of 
Counter-stimulus, I would say, that— 

" If the patient be much enfeebled, and the powers of reaction weak, mercury 
continued to any extent, goes on debilitating-, and finally prostrates the vital 
energies; or should ptyalism be induced, the fever or reaction is ephemeral, and 
the same train of alarming symptoms come on as before, which are only relieved 
by cordials and stimulants. Whatever may have been the speculative opinions of 
those who practice in warm climates, they are soon forced to confess, from the 
irresistible testimony of experience, that mercury is illy borne by weak habits-— 
that it induces great debility in the digestive, nervous, and muscular organs, by 
no means proportionate to the duration of the previous slight mercurial fever which 
is principally kept up by the irritation of sore gums. Hence, in summing up, we 
find, in the first place, that mercury is thought to be best adapted to diseases of 
high action, in which it is given in conjunction with depleting and counter-stimu- 
lant remedies ; and secondly, that if we employ it to any considerable extent, it 
produces great and serious debility, and often an entire prostration of the powers 
of life, and that the most active cordials or stimulants are demanded to palliate 
such effects." 

It may be alleged, in reply to this view of the depressing action 
of calomel, that in diseases of a highly inflammatory character it 
is necessary to reduce the excitement before we can obtain the good 
effects of the medicine. But the fallacy here consists in making 
the specific effect, or ptyalism, synonymous with its chief, remedial 
action. Calomel acts on the nervous system, but not in as exclusive 
a manner as quinine ; its operation is soon extended to the vascular 
system, and more particularly to the interwoven nervous and capil- 



602 



CONGESTIVE FEVER. 



lary portion — that through which secretion and nutrition are mainly 
performed. In a moderate dose, and for a limited period, it exerts 
a beneficial action on secretion ; continued too long, it notably de- 
ranges this function, and with it the closely allied one of nutrition, 
which is, in fact, but modified secretion. Whenever this action of 
parts is in excess, calomel tends directly to restrain excitement by 
its sedative action. Whenever the state is converted into one of 
anaemia, it attacks the nutritive process, rapidly deteriorates the 
functions of assimilation, and hurries the disease to a fatal ter- 
mination. Thus, in chronic inflammation of an organ, which keeps 
up perpetual irritation of the general nervous system and indirectly 
enfeebles the whole animal economy, calomel or blue pill will reduce 
the local excitement and phlogosis ; and, by withdrawing the source 
of irritation and indirect debility, it will seem to strengthen the patient. 
But if, from a mistaken notion of its being really a stimulant or a 
tonic in fever, or of that most indefinable of all its virtues, an alterative, 
it be persevered in after the removal of the inflammation, the patient 
soon learns to his cost that his state of amelioration was transient, 
and that with a rapid decay there is a real breaking up of the tissues. 
In the diseases, such as scrofula, pulmonary consumption, and 
scurvy, in which, although there be inflammation, yet the chief and 
most serious ground for alarm is deteriorated nutrition, calomel or 
other mercurial preparation used to any extent singularly exas- 
perates the disease. In simple inflammation, uncombined with tuber- 
culous formations in the lungs, as of the bronchia, lungs, and pleura, 
mercury is a useful adjuvant to blood-letting, and will on occasions 
supply its place. As in the operation of other medicines avowedly 
sedative, so in the midst of mercurial depression there may origi- 
nate congestion of an organ, or inflammation, as of the salivary 
glands, which will be followed by febrile reaction ; but this soon 
subsides, and unless proper measures be taken, the chief of which 
is a cessation from the use of the medicine, the depression continues 
until the organic actions are enfeebled beyond recovery. I pointed 
out the fallacy of making ptyalism, or the specific action, as it is 
called, of mercury, represent the series of mercurial effects of a 
more salutary and benign kind, which are anterior to this result and 
are best obtained without it. That calomel is apparently powerless 
in states of great morbid excitement is no proof of its not having a 
counter-stimulant or sedative operation. Blood-letting, antimony, 
digitalis, are on occasions inefficient to reduce such inordinate ex- 
citement ; but the want of impressibility of the human frame at 
particular times by an agent, is no argument against the known and 
generally evident properties of this latter. 

Regarding it then as a depressing medicine of no small power, you 
will give calomel in the exacerbation of fever as a simple febrifuge, 
without measuring its effects by its incidental purgative operation, 
and certainly without blindly urging its repetition until it pro- 
duces ptyalism. As the best febrifuge effects of tartar emetic are 
not obtained when it vomits or even nauseates, so neither are those 



CALOMEL AND QUININE. 



603 



of calomel to be sought for from its purging. If you are persuaded that 
in the remission there is still irritation, calomel may be given, and 
if its action be of the nature which I have explained this medicine 
will be of service. Annesly claims it as an anti-periodic in the 
fevers of the East Indies ; and although not at all comparable to 
bark or quinine in this repect, both on account of its inferior effects 
on the nervous system and its tendency to interrupt the nutritive pro- 
cess, it is at times worthy of trial. It is now several years since I 
noticed the harmony of action, in intermittent fever, between mer- 
cury and bark, and prescribed the two medicines accordingly, in 
the manner mentioned in my remarks on intermittent fever, addi- 
tional to the lecture of Dr. Stokes on that disease. I there said : 
"Not unfrequently, when the disease prevailed so extensively in 
this city and its vicinity a few years ago, I gave a five-grain pill 
of the blue mass at night and the cinchonic preparations during the 
following morning, with the effect of promptly arresting quotidian 
fevers, which had not yielded to the bark alone, The practice is 
equally applicable to tertian fever." I find that many physicians 
in the south and west are in the habit of prescribing calomel and 
quinine in combination, in the congestive or malignant double 
tertian fevers of those regions. Dr. Drake, in a passage which I 
quoted from his journal, adverts to it in terms of approval. Dr. 
Hogg, in his account of the epidemic fevers of Natchez in the years 
1837-'8-'9 (Western Journal), takes brief notice of the malignant 
double tertian, and mentions the calomel and quinine practice in the 
following terms: — 

" Whenever the action began to decline, full closes of quinine every second or 
third hour, alternated with ten-grain doses of calomel, with sinapisms of mustard 
to the extremities, prevented a return of the chill and torpor. The medicines 
were then continued in small quantities, and at large intervals, until the secre- 
tions became natural and the patients convalescent. The following is my mode 
of administering the quinine. R. Sulph. quin. grs. x., Pip. nig. ol. gr. i. M. ft. 
pil. : one to be taken every hour, or once in two hours. 

"When the patient was not seen before the second chill, the extremities were 
dry and cold, stomach very irritable, contents of the bowels liquid ; a warm mustard, 
pepper, or salt bath, or mustard sinapisms to the stomach and extremities, blisters, 
quinine, as above prescribed, alternated with calomel twenty grains, sulph. morph. 
1-6 grain, together with warm stimulating drinks, seemed to snatch the patient 
from the jaws of death, and relieved him, contrary to the expectations of friends, 
or physician. Injections of strong salt water were used to empty the bowels when 
necessary." 

Whilst, on the one hand, it is a matter of positive experience 
that new and beneficial effects are obtained by combinations of 
medicines, it is equally certain that two articles have often been given 
together from very crude h priori opinions of their joint operation. 
Some persons seem to think that, in combination, each medicine retains 
a portion of its primary and well-known property, and that it is only 
corrected in its excess by its associates. Thus, the common febri- 
fuge powder of nitre, tartar emetic and calomel, is supposed to pre- 
sent the combined virtues of the three articles; whereas in fact it 
often prevents the patient from realising the salutary operation of 



604 



CONGESTIVE FEVER. 



any one of them. The nitre in solution largely diluted would act 
usefully on the kidneys ; in powder it often irritates the stomach, 
and increases thirst : the tartar emetic, sometimes nauseates to 
such a degree as to prevent a continuation of the compound, and 
of course of the calomel, which, given alone, might prove tranquil- 
izing to the irritated and inflamed stomach and intestines ; whilst a 
change in the mode, or time, of administering the tartar emetic would 
enable the patient to receive and be benefited by it. Weoughttoknow 
much more than we do of the regular physiological, as well as the- 
rapeutical effects of each of the medicines in common use, before 
we hazard a combination. The spirit which dictated the compo- 
sition of the Theriaca and the Mithridate is not inactive among us. 
Empirical experience may on occasions be relied on, although the 
hypothesis which gives it a philosophical sanction is erroneous : 
as when it was assumed that intermittent fever was a disease of 
debility which quinine cured by its tonic or permanently stimulating 
action. Butthat, which was harmless in the given case, becomes mis- 
chievous when an attempt is made to enlarge the proposition by the 
introduction of one or more new elements. Thus, from the assumption 
respecting the manner in which bark operated, a corollary has been 
drawn, that its adjuvants and congeners could be taken from the class 
of diffusible stimulants whose basis is alcohol. The practical conse- 
quences of this error were frequent disappointment in the use of the 
bark thus combined, by the conflicting operation of alcoholic excite- 
ment and cinchonic sedation ; and attributing to the bark irrita- 
tion, congestion, and phlogosis of an organ, such as of the stomach or 
intestines, the spleen or liver, which was, if not originally caused, 
at least kept up by the spirits or wine, in which the former was 
infused, prior to its administration as tincture, &c. Happily, 
with a better pathology of periodical fever, there is a coinci- 
dence of the discovery of quinine, and a wiser and more natural 
hygiene ; so that, now whilst we admit the not unfrequent addition of 
inflammation to the fever, we can give quinine without the various at- 
tempts, once so common in the case of bark, to disguise its taste by 
vinous and spirituous menstrua ; and the bad plea is no longer urged 
in favour of this practice, that it is favourable to health and to 
the warding off of fever. A man can now be cured of a febrile 
disease, and particularly a periodical one, without the risk of his 
becoming subsequently a drunkard, in consequence of the taste ac- 
quired and the habit of drinking wine and spirits both with and after 
his bark, under the direction of his physician. Do not, therefore, 
I beseech you, give into the once general, and yet too common error 
of believing, that when you prescribe quinine, brandy and volatile 
alkali, you are directing medicines of the same class and of similar 
operation. 

On the febrifuge virtues of tartar emetic in congestive fever, it is 
not necessary for me to descant, after the adequately full remarks 
in a former lecture on the use of this medicine in typhous fever. 
With a view of bespeaking your farther attention to the subject, I 



SECONDARY CONGESTIVE FEVER. 



605 



will just add that tartar emetic has been eulogised as an anti-periodic, 
| capable, in union with opium, of curing intermittent fevers. Originally 
prescribed by Hufeland, this combination acquired most vogue in 
the hand of Peysson. His formula was, a grain of tartar emetic 
I dissolved in eight ounces of water, to which an ounce of syrup of dia- 
codium, or of poppies, with alittlegum arabic and orange-flower water 
! — a scruple of the former and two drachms of the latter were added. 

Of this, during the interval, a table-spoonful wasgivenin the morning, 
| and the dose gradually increased, so that twice this quantity was 
given at the expiration of an hour, three spoonsful of the second 
hour, and so on until dinner time. After the lapse of an hour and 
a half from this time, the use of the mixture was resumed, and the 
j dose gradually increased as before. Another plan, with a person 
I of a delicate frame and who could dispense with solid aliments, was, to 
give him a spoonful at first every hour, and afterwards to diminish 
the interval, so that a dose should be taken every fifteen minutes, 
: or at the most every half hour. 

Thus far I have addressed you on the subject of primary 
congestive fever. The secondary form is of still more frequent 
occurrence, as it is not only one of the terminations of the pri- 
mary, but also constitutes the latter stage of the common remit- 
| tent under the name of secondary typhous or typhoid fever. The 
prolongation of the fever in these cases depends chiefly on the 
phlogosis of some important tissue, the arachnoid of the brain, or 
the mucous of the digestive canal, — and, on occasions, of the brain, 
liver, spleen, and lungs respectively. Of the best means of com- 
bating the most dangerous symptoms, and of obviating the inci- 
dental disorders which spring up in this stage of fever, Dr. Stokes 
has spoken so instructively, that I can, with entire confidence, 
refer you to his lectures, in which, together with my first one in 
the additional series, you will meet with positive directions and 
pregnant hints calculated for your guidance in nearly all the emer- 
gencies of any case which will come before you. I could wish, indeed, 
did time allow, to expose the fallacy of that still too current creed 
which supposes that mercury as a sialogogue is an adequate or at 
all an uniform remedy in the complicated and worst forms of fever. 
The mere fact, that persons labouring under ptyalism and regular 
mercurial disease have been attacked with fever, and sunk under it 
without mitigation of symptoms as fast as others to whom mer- 
cury had not been administered at all, ought to suffice for illustra- 
tive proof of the error of the popular doctrine on this score. Scarcely 
better founded is the notion that the inflammatory congestions, which 
are the occasional sequelae of the fever, require for their removal a 
mercurial course — blue pill or calomel and opium internally, and 
blistering and subsequent inunction with mecurial ointment exter- 
nally. I would not proscribe this practice entirely, but would re- 
commend, as much more worthy of adoption, that of cupping over 
the congested organ, spleen for instance, and then rubbing the part 
with the ointment of the hydriodate of potass night and morning, and 

52 



606 



CONGESTIVE FEVER. 



the administration of a solution of this salt in camphor or mint water. 
The dose to be begun at two grains and gradually increased to five 
twice a-day. In cases of enlarged and indurated spleen, quinine 
has been taken with excellent effect. From the alternation of quinine 
and iodine, or of blue pill, you may hope to procure the most satis- 
factory results — either of the latter being directed at night, and the 
former in the morning. 



LECTURE VIII. 

Blood-letting and quinine successfully employed by Dr. Bailly, and in the Roman hos- 
pital — Summary of the curative course in congestive fever — Calomel,— its operation 
on the nerves and capillaries, and on the secretory and nutritive organs — Cures in- 
flammation by attacking nutrition — Poisonous effects of mercury when long conti- 
nued — Clinical inference — Congestive typhus — Armstrong's cases — Their resemblance 
to malignant tertian fever — Armstrong's treatment. — Fallacy of belief respecting mer- 
curial ptyalism — Natural or spontaneous termination of remittent fever — Tantini's 
cases. 

Having introduced to your notice a number of the fatal cases 
recorded by Dr. Bailly, it is but right, before I dismiss the subject 
of the details of the treatment of congestive fever, to mention some 
of the bad cases the subjects of which were restored to health. 
They will serve to illustrate the advantages of blood-letting and 
bark or quinine in this disease, when neither of these remedies 
alone would suffice for a cure : some of them also show the large- 
ness of the dose of quinine, and the benefits derived from a combi- 
nation of calomel with it. 

One patient, the doorkeeper of St. Peter's church, had taken a hundred grains 
of the sulphate of quinine in four to five days, as well as several doses of purga- 
tive medicine : the fever disappeared in about ten days, but it returned in three 
weeks afterwards. The use of four ounces of bark and fifty grains of the quinine 
in ten days, again stopped the paroxysms. In a short period from this time a 
fresh attack, for which twenty grains of quinine had been taken in vain, induced 
him to ask advice from Dr. Bailly. This gentleman prescribed venesection, 
which was performed ; but was followed by a very restless night, with great pain in 
the knees: — the blood was covered with a layer of transparent and gelatiniform 
albumen — the coagulum very firm and resisting. The patient was bled again the 
next day ; and ligatures were applied to the limbs half an hour before the expected 
return of the fit, which formerly came on at noon. But the cure was complete ; 
there was no fresh paroxysm during the remainder of the season, and the winter 
was passed without a relapse. 

The second case was of an Irish priest, who was seized in the latter part of the 
month of August, 1822, with a pernicious intermittent fever — the chief and most 
violent symptom of which was so acute a pain in the head that this part seemed to be 
penetrated by a red-hot iron. On the day after the fit he was bled to the amount 
of a pound — but a fresh one returned in the evening with all the intensity of 
the first. A second bleeding, equal to the first, was practised on the following 
day, and after it he took a mixture of twenty grains of calomel and ten of quinine, 
— in two doses at an interval of two hours; and subsequently, every two hours 
through the day, a paper containing five grains of quinine. He had six alvine 
discharges in the course of the day ; no return of fever in the evening. 

The third case was of a young Irishman, twenty-two years of age, living in 
Rome, in whom the accession of the fever was accompanied with a horrible 
pain in the abdomen, which was pressed on by his hands, and which elicited from him 



BLOOD-LETTING AND QUININE. 



607 



loud cries; the tongue was whitish, and without redness or dryness; there was no 
I thirst— -the pulse was full and round. Dr. Bailly directed a pound of blood to be 
taken from his arm and twenty leeches to be applied to the abdomen: an abatement 
j of the paroxysm in the evening was followed the next day by an entire remission 
I of fever and pain; both of which, however, returned on the second day, preceded 
I by chill and fever. The treatment was the same as that on the first day, viz. : 
J venesection and leeching in the same quantity and number as before, and demulcent 
j drinks. On the fourth day there was apyrexia like the second, and on the fifth day a 
] third accession ; with this difference, however, that notwithstanding all the tossing 
j about, and anxiety and despondency, when asked what he complained of, he could not 
designate any particular spot, and replied that he did not feel anything the matter with 
him. This paroxysm, as it did not indicate danger, was allowed to pass without any 
j remedy being taken : in the evening it subsided entirely, and the patient rested well 
through the night as he had done on former occasions. Dr. Bailly prescribed for 
! the following day, that of apyrexia, three doses, each of five grains of quinine, to 
j be taken in this period. On the seventh, which would have been the day of his 
j paroxysm, he escaped with a feeling of general uneasiness. He continued the sul- 
: phate of quinine some days, and his cure was complete. 

Another case was of a woman, aged twenty-one years, who had been sick for 
nearly five months with an intermittent fever, which resisted several ounces of 
j bark, and finally became a continued one. Dr. Bailly, after inquiry into the 
j history of the case, was induced to believe that it was one of a masked or subintrant 
intermittent; and he began the treatment by a large bleeding: the reaction during 
the ensuing night was excessive, the fever higher than before, and the woman 
was delirious. The blood was dense and gelatinous, without a buffy coat. A 
second bleeding was followed by nearly the same symptoms as the first ; but the 
delirium was less. On the third day a third bleeding was practised ; and the 
paroxysm of the night was followed by a sweat and a remission in the morning. 
The day was passed tranquilly ; but there was a fresh paroxysm at night and a 
I sweat and remission the next morning. Dr. Bailly, desirous of terminating the 
fever, and of economising the time of the patient, directed sixty grains of quinine 
in two days. The first doses stopped the paroxysm, and forthwith convalescence 
began, and was followed so speedily by such good health that this woman gained 
flesh in the course of a few days, and soon recovered the colour and fulness of 
habit which she had been deprived of for the five months preceding. The 
menses, which had been suppressed from a date anterior to her first attack, re- 
turned in a week after her cure without any special remedies for the purpose. 

A case of comatose pernicious fever was ushered in by a paroxysm which lasted 
from the 7th of August (1832), to the morning of the 9th. On the 10th, at three 
o'clock, p.m., there was a fresh paroxysm, marked by stupidity, wandering looks, 
difficulty of opening the mouth, flexion of the right fore-arm, vibration of pulse. 
Venesection eight ounces, sinapisms to the feet. Pulse 120 after the bleeding; 
rigidity of the fore-arm almost gone ; opens the mouth; complains of headache : 
there is general restlessness. Venesection again at seven o'clock in the evening, 
eight ounces, and a pediluvium of 120° F. At ten o'clock in the evening an entire 
restoration of consciousness ; cessation of rigidity of the arm. The patient says 
he is very well, except that he has a slight pain in the supra-orbital region. He 
had some alvine evacuations: pulse 100°, thirst considerable (Bark an ounce). 
On the morning of the 11th, is free from fever; pulse 90°; perfect remission 
(Bark three ounces). 
The next was a case of gastro-cephalic pernicious fever, with very violent symp- 
I torn s, of seven days' duration, although the patient, a girl four years old, did not 
j leave the hospital until the 12th day. The accession came on after a fall down 
stairs, which frightened her very much. On the occasion of the second paroxysm, 
j second day from that of the first, accompanied by violent fever, vertigo, suffused 
face, great anxiety, she had a saline potion, and an enema of chamomile with an 
J ounce of vinegar given to her : eight leeches were applied to the temples. In the 
night there was a slight perspiration and alvine discharges. On the next day 
I 13th of August ; the pulse was small and frequent; countenance heavy; stomach 
painful under pressure ; tongue moist and red on the margin (mucilaginous drink, 
eight leeches to the epigastrium, followed by a cataplasm of bread and milk) : much 



608 



CONGESTIVE FEVER. 



blood flowed from the leech-bites. In the evening: apyrexia, still anxious and 
dull expression (sulphate of quinine, fifteen grains in three doses; enema with 
an ounce of bark, which she retained ; but the quinine was thrown up by vomit- 
ing). By ten o'clock in the evening, the extremities were cold and, covered with 
a viscous sweat ; she vomited another dose of the quinine. 14th. Together 
with other bad symptoms, small and frequent pulse, &c, the pain in the stomach 
was excessive, and would not allow of her bearing the slightest touch ; tongue dry, 
dotted with red and developed papillae ; continual sighing. She complains of her 
head as if there was something in her brain; continual cries, like those uttered by 
hydrocephalic patients (Emulsion; a bath of 92° F.). She remained half an hour 
in the bath, and said she was relieved by it. Evening: continual somnolency and 
headache ; pain of the stomach disappeared, inextinguishable thirst, moist tongue, 
continued anxiety (Saline potion, mustard and vinegar pediluvia). 15th. Morn- 
ing : apyrexia, but restlessness, anxiety, and somnolency ; pains of the head and 
stomach gone; noalvine discharge for two days past (Sulphate of quinine ; fifteen 
grains divided into three doses ; enema). In the evening : exacerbation ; skin 
burning, particularly that over the abdomen (Bath, 88° F. ; enema ; sulphate of 
quinine in four doses). After the bath, feels more comfortable ; has vomited one of 
the doses of the quinine. 16th. Morning : weak stomach ; pulse 107°; no headache ; 
continual groans, and restlessness; abdomen hard, tongue dry (Sulphate of 
quinine, fifteen grains in three doses ; lemonade ; enema). A dose of the quinine was 
vomited. Evening : apyrexia, but a feeling of discomfort and general debility ; bowels 
still constipated (an enema of chamomile which had no effect; one of castor oil, 
an ounce, produced an evacuation). In the night, partial sweats. 17th. Apyrexia ; 
general weakness; but the patient herself admits that she is well (Enema). 

The last reported case is that of a soldier, thirty-six years of age, of a good con- 
stitution, who had intermittent fever, accompanied with pain in the stomach 
the preceding year. On the 6th September, 1822, he was anew the subject 
of fever, the paroxysms of which began and terminated in the common way. On 
the 7th, while the fever was yet on him, he washed his pantaloons at a fountain, 
and chilled his hands and feet, which he was unable again to warm. He suffered, 
at the same time, from a feeling of intense heat in the abdomen, chest, and head : 
in the night he had but a partial sweat on the forehead. He entered the hospital 
on the evening of the 9th of September; at which time he exhibited the following 
symptoms : an icy coldness of all the limbs ; the hands, which were of a natural 
colour, looked as if they had been macerated in cold water — they were rather 
violet than pale: abdomen painful, inward burning; thirst, great distress; 
pulse not to be felt at the wrists, temples, and heart, and almost imperceptible at 
the crural artery ; look stupid, but without any disorder (decomposition) of fea- 
tures, which differed little from the common state. One would never have sup- 
posed from his facies that the patient was in such a condition. Tongue moist and 
natural (twelve leeches to the anus). At nine o'clock in the evening the cold 
was more intense ; the skin of the limbs, abdomen, and chest, being of an icy cold- 
ness ; pulse imperceptible, but he retains his intellect. His appearance is that 
of a man who is calm and tranquil: the colour of his face is like that of a person 
in health, and is of a reddish hue. 10th September. Pulse in the morning, 108 
at the crural artery ; pains in the abdomen increased by pressure ; the patient 
compares them to a feeling of tearing; respiration loud; tongue moist, yellow 
in the middle; a slight headache (Bath of 88° F. ; an ounce of bark which he 
vomited entirely). After the bath, pulse 120; countenance still natural; skin 
rather less icy ; burning heat inwardly; pains of the stomach and vomiting continue. 
Before the bath the thermometer, held some seconds in his hand, fell to 81° F., 
the temperature of the external air being 100° ; at the groin it rose to 100°. I 
shall not repeat, for want of room, a detail of the symptoms recorded by Dr. Bailly, 
but give the outlines of the treatment. In the evening a mustard pediluvium, 
sinapisms to the legs, and blisters to the arms were directed. In the night he 
had vomiting, and extremities still cold (twelve grains of the quinine and a 
warm bath were taken). After the bath the limbs became warmer. Sweated so 
as to moisten a shirt. The temperature then sank; the pulse again became im- 
perceptible ; but the patient says he is less oppressed. Vomiting still persists. 



% 



SUMMARY OF TREATMENT. 



609 



12th, Morning: limbs less cold; pulse to be felt, and 84°. Afternoon: reaction ; 
I less distress. (A pound of blood is taken from the arm) — it was dense, some- 
what buffed, and showed little serum. Pulse 80; temperature of the skin 
natural; tongue moist. At ten o'clock, same state; hiccup from time to 
I time. (Another venesection to the extent of a pound of blood.) Blood some- 
| what buffed, and dense. Sweats in the course of the night. 13th. An 
] abatement of disease ; internal heat gone, and head clear. Bowels moved. In 
I the evening, twelve grains of sulphate of quinine were prescribed. On the 14th, 
| in the morning, the skin was warm ; but the patient after having been up in his 
j shirt using the close-stool had a coldness of the limbs, which took some time to 
I disappear: irritation of the throat ; tongue natural. In the evening : the skin was 
warm ; pulse strong and full ; hiccup returned ; tongue dry in the centre. (Ptisan ; 
j ' venesection to the extent of a pound of blood, which was dense and somewhat 
buffed.) Night tranquil, and general sweat. 15th, Morning : pulse equable and 
natural ; no hiccup. (Twelve grains of the sulphate of quinine were prescribed.) 
j Evening: same state. 16th. Bark in decoction. 17th; The patient eats with 
I appetite. 18th. Well ; leaves the hospital. 

If we were to draw inferences with any degree of positiveness 
I in favour of a remedy from the salutary turn which the disease 
! took after its use, we should say that the venesection in the prece- 
l ding case was the chief means of removing the excessive coldness 
and other alarming symptoms. We must not compare this coldness 
to the chill and rigors in the paroxysm of a fever, since the former 
persisted in different cases of the algid variety, although the disease 
went through its customary periods of exacerbation and interval. 
The preservation of the natural expression of the countenance and 
| of the intellect in connexion with the vomiting, excessive abdominal 
heat, and often pain and throbbing, showed the viscera of the abdo- 
men to be the parts which chiefly suffer. 

Separating the directions for the treatment of congestive fever 
from the inquiries into general therapeutics, which might I thought be 
made to bear usefully on the subject, you will see that the former are 
applicable to — 1, the period of invasion, and before the disease has 
declared itself with its characteristic and violent symptoms; 

2, the stage of depression, commonly of chill, and often disturbance of 
innervation, and consequent congestion of one or more organs ; 

3, the stage of reaction, in which the disease assumes a more ex- 
pansive character, and approaches in its nature to the hot stage of 
a common intermittent or remittent fever, but still exhibits evidences 
of oppressed functions, and more particularly of imperfect inner- 
vation and laboured circulation. 

In the first stage, or that of invasion, the treatment is simple, 
but if carried out fully, will be efficacious. Its outlines are, rest 
i for the functions of the nervous and muscular systems, and best 
j in bed, with an avoidance of all the stimulants of light, sound, and 
, addresses to the feelings and intellect ; simple diluent drinks; an 
enema to evacuate the lower bowels ; and warm water, or a few 
grains of ipecacuanha if the stomach be obviously distressed by the 
remains of the last meal, or if there be nausea and retching. The 
addition, after the vomitinghas ceased and the subsequent diaphoresis 
is over, of a mild laxative, if pain in the head and limbs and in- 
cipient febrile irritation are present, will often suffice for a complete 

52* 



610 



CONGESTIVE FEVER. 



removal of the disease. But time must be allowed after the ces- 
sation of apparent disease, in order that the nervous system may 
go through its diurnal circle of functional and organic acts, and 
proof be afforded of its immunity from a recurrence of the primary 
symptoms, with perhaps aggravations. Hence, an invalid who sub- 
jects himself to domestic or formal medicinal treatment for twenty- 
four hours, ought to let a period of the like duration elapse before 
he encounters a renewal of his out-door or other active engagements, 
and returns to his customary food. 

The remedies during the stage of depression with congestion — 
indicated by rigors, cold, small, and frequent or intermittent pulse, op- 
pressed breathing, and feebleness of the intellect and senses, in- 
ternal heat and thirst, are to be addressed primarily to the nervous 
system, and notably to its expansions on the skin and mucous mem- 
branes. To the first of these surfaces we apply assiduous and ex- 
tended friction, the warm water bath, or warm air bath; to the 
latter tepid or cold water, according to the sensation, and opium 
either by the mouth or enema, If we know the state of the ali- 
mentary canal to be such that it is partly occupied by irritating 
matters ; for, food in the stomach and feces in the colon, in the now 
irritable state of the mucous surfaces, are irritants, these ought to 
be first removed by the means already indicated, and then, if 
reaction is tardy and imperfect, the opium may be given. 

In all this stage, which, though one of depression, is also of irri- 
tation, and not seldom of congestion and inflammation combined, we 
must abstain from the stimulants whose action is chiefly on the ner- 
vous system. Mild counter-irritants to the skin, and sedative treat- 
ment for the mucous surfaces — after their material irritants are re- 
moved — will express the outlines of treatment ; which does not there- 
fore embrace either cauterization or disorganizing action on the 
skin, nor brandy or other analogous liquors internally. Of the coun- 
ter-irritants, sinapisms kept applied, or dried mustard rubbed on the 
inside of the legs, thighs and arms, until sensation of a positive but 
not painful kind is produced, are useful. 

Fulness of habit, previous plethora, the probable prior existence of 
inflammation of the gastro-intestinal surface, or of the liver and spleen, 
or brain and its meninges, and incipient reaction yet still remaining 
oppression, will justify the opening of a vein and allowing a small 
quantity of blood to flow out. The diminution of the oppression 
and the persistence or development of fixed pain in an organ pre- 
viously disordered, will indicate the advantage of taking away more 
blood at this time. But if doubts are entertained of the powers of 
reaction, or of the tolerance of the system under the sudden abstrac- 
tion of blood, which may still be called for by other circumstances, 
then must recourse be had to leeching, or what is still better, to 
cupping, for reasons already assigned. 

The doubts expressed both of the philosophy of the theory laid 
down for bleeding in the cold, or first and depressed stage of con- 
gestive fever, and of the benefit actually derived, would make us 



REAL VALUE OF MERCURY. 



611 



content to watch returning action of the organs under the operation 
of other means, and as a result of the simple recuperative powers of the 
animal economy. The excitement general and fully established, in the 
hot stage of the paroxysm, we can now, with a better measure before 
| us of the state of the organs and of the probability of their labour- 
\ ing under inflammation, have recourse to blood-letting. But unless 
! the indications of this nature be clear and decided, we must not 
; allow the symptoms of febrile exacerbation to impose on us as evi- 
| dences of inflammatory action. High as simple excitement may 
run at this time, it has, we cannot forget, its limits of time and inten- 
. sity, and will after a period terminate in sweat or some other ex- 
cretion. These discharges are however not the causes but the 
effects of abating and subdued irritation and excitement. It will, 
j therefore, be our clear duty to imitate nature in this respect, and 
to endeavour to procure an abatement of the excessive action — cer- 
tainly not to increase it. Hence, if we desire to produce secretion 
! from glands and mucous and cutaneoussurfaces,the meansoughttobe 
such as diminish nervous irritation and capillary excitement, which 
are the obstacles to such secretion. With this view, after blood-letting 
if it has been required, will come cold or tepid affusion, or sponging 
j the cutaneous surface ; cool or cold drinks, simple or mucilaginous, 
j slightly acidulated or bitter ; and cold or tepid enemata. Calomel 
will be given at intervals during this stage, not to stimulate or force, 
i the secretion, but to bring the organ, the sanguineo-nervous texture 
particularly, down to the secreting point. It is in this way a pre- 
cursor to and ally of quinine, whose action is mainly restricted to 
the nervous system alone. Calomel, or mercury in general, acts on 
thenervous,but it also acts on the capillary texture, the termination or 
ramifications of which latter are the common and nutritive secretors. 
When it excites nausea and sickness of stomach, the effects are quite 
different from those which accompany gastritis or the exacerbation of 
fever ; they are proofs of a depressing action on the nervous system 
analogous to that in sea-sickness and recovery from syncope. 

In most cases of nervous excitement or of irritation, associated 
with vascular action and inflammation of tissue, mercury is of 
service. In most cases of nervous debility and of diminished vas- 
cular action, and in imperfect cohesion and nutritive formation of 
tissue, mercury is injurious. Both its good and its bad effects are 
j manifested on the nervous system and the capillaries. If persisted 
| in after these are reduced to the line of simple healthy excitement, 
it acts as a true poison : — it attacks the vitality of the organs, and 
destroys their organic tissues, by preventing assimulation and 
nutritive secretion or deposit. Hence, efficacious as it often is in 
inflammation, particularly of glandular and membranous textures; 
we must never forget that it is so by its action on the nutrition of 
these parts, and that whilst it allays nervous and capillary action, 
and encourages interstitial absorption in the inflamed tissue, its ope- 
ration on the healthy tissue is analogous. In proof of this, I may 
mention the great emaciation and languor, together with mental 



612 



CONGESTIVE FEVER. 



inaptitude, weakness of the senses, and excessive muscular feeble- 
ness, which are so often the effects of a protracted exhibition of 
mercury, and when it has produced what is termed its constitutional 
effects. Instances are recorded in which sudden death has occurred 
in mercurial disease, apparently in consequence of a very trifling exer- 
tion or agitation. Such cases have been described by Mr. Pearson, 
under the title of mercurial erethism. This state is, he says, 
characterized by great depression of strength ; a sense of anxiety 
about theprascordia; irregular action of the heart; frequent sighing; 
trembling, partial or universal; a small, quick, and sometimes inter- 
mitting pulse ; occasional vomiting ; a pale, contracted countenance; 
a sense of coldness. Among the anomalous complaints arising from 
a course of mercury, or its frequent use in delicate individuals, and 
especially females, Dr. James Hamilton enumerates impaired or 
capricious appetite, with all the ordinary symptoms of indigestion, 
particularly retchings in the morning, flatulency, disturbed sleep, with 
frightful dreams; impaired or depraved vision; frequent aches and 
pains in different parts of the body ; occasionally such sudden failure 
of strength, as if just dying ; and at other times violent palpitations 
of the heart, accompanied with difficulty of breathing. Tremors, 
paralysis, and incurable mania, have been, on occasions, produced 
by mercury. " I have myself," adds Dr. Falconar, " seen repeatedly, 
from these causes, a kind of approximation to these maladies, that 
embittered life to such a degree, with a shocking depression of 
spirits and other nervous agitations with which it was accompanied, 
as to make it more than commonly probable, that many of the 
suicides which disgrace our country were occasioned by the in- 
tolerable feelings that result from such a state of the nervous 
system." If mercury sometimes correct redundant nutrition by 
the removal of tumours and healing of inflamed sores, it too often 
aggravates scrofulous enlargements, and brings on and increases 
ulcers in the throat and nose, and caries of the bones. 

The object at which 1 aim, in placing this picture before you of 
the multifarious disorders and positively poisonous effects caused by 
mercury, is to show that we are not justifiable, nay, we are criminal, 
if we fly to this agent on every occasion, under the plea of one hy- 
pothesis or another. Now it is to reduce morbid excitement, then to 
equalize the circulation ; this week to restore the secretions, the next 
to correct them ; one time as a purgative, another as an alterative ; a 
third as a sialagogue. To-day, a physician gives it in a case of 
fever to relieve congestion and induce reaction ; to-morrow, to 
moderate that reaction; a few days afterwards to unlock the liver; 
then to relieve the lungs, and finally to cure delirium: he gives it to 
carry out a particular indication — he gives it when he is at a loss what 
else to do. He begins and he ends with mercury : he poisons in- 
sidiously when he continues to prostrate the system, and brings on 
anomalous symptoms ; all the time alleging that the medicine has no 
effect, because it does not salivate. He poisons openly when he 
gives notice of his intention, and carries it out, too, by administering 



CONGESTIVE TYPHUS. 



613 



the calomel in such doses, and with such results, as to salivate long 
and profusely; thus throwing open the constitution of his patient to 
the morbid influence of atmospherical changes and other causes of 
disease. Scrofulous aggravations, rheumatism, disorders of the 
kidneys and skin, and consumption itself, are some of the fruits of 
this new state of things. 

Let us then revise our general and special therapeutics in their 
adaptation to the treatment of various diseases, and ask ourselves, 
whether a necessity exists for giving calomel in all diseases or even 
in a majority of them ; and whether we ought not to have very pre- 
cise and positive indications for its use before we venture to pre- 
scribe it at all. At the most, these indications cannot vary from 
day to day and hour to hour ; and when once they are fulfilled, or 
attempted to be fulfilled without success, then ought the use of the 
medicine to be desisted from at once. It would be just as reason- 
able to overlook the proper medicinal effects of opium as an ano- 
dyne, a hypnotic, and a diaphoretic, in favour of the narcotism which, 
when given in excess, it is so apt to produce, as to disregard the purga- 
tive, sedative, and secretory virtues of calomel in favour of its siala- 
gogue and poisonous operation. Nor ought the first and most obvious 
effect of calomel on the stomach and intestines, and indirectly on 
the liver and pancreas, to make us disregard its more permanent 
and diffusive influence on the nervous and nutritive systems, includ- 
ing not only the brain and senses, but the organs of locomotion, and 
the membranes — mucous, cutaneous, serous, and fibrous — as well 
as the parenchymas of the organs generally. 

I have hitherto purposely endeavoured to fix your attention 
on the country congestive fever, as that which, in its different 
varieties, will most frequently present itself to you ; and on the 
pathology and treatment of which you will be properly expected 
to have definite notions. I also enlarged most on the primary 
form, that met with in the beginning of the fever, and which 
imprints its character on the disease in its subsequent course. 
I stated, however, that you must expect to meet with the se- 
condary form, commonly called typhoid or even typhous fever, 
which it resembles in many of its symptoms of functional dis- 
turbance and organic lesion of the brain and its meninges, and, 
also, lungs, heart, stomach and intestines. But in typhous and 
in typhoid fever, also, these organs are apt to be oppressed from 
the beginning in a peculiar manner — comparable to the opera- 
tion of poisons on the animal economy. Ample details, and as I 
believe useful general principles for your guidance, have been placed 
before you in the lectures professedly on these fevers. But even these 
diseases are, on occasions, characterized from the outset by a series 
of symptoms that more particularly entitle them to receive the 
qualifying epithet of congestive. Such varieties as this are more 
common in crowded populations; the members of which are 
in an especial manner exposed to causes calculated to develop 



614 



CONGESTIVE TYPHUS. 



them. Of these, the chief are a close and impure air, both by defi- 
cient ventilation and the accumulated exhalations from so many- 
living bodies ; excessive and prolonged excitement of the brain and 
senses in the schemes of business, the dreams of ambition, and the 
multifarious appeals to sensuality of all kinds. The nervous sys- 
tem, thus irritable and weakened by excess, soon feels the shock of 
atmospherical change or alimentary privation, and typhous fever will 
be a consequence of the transition. I know that Dr. Armstrong 
who at first insisted on the contagious nature of typhous, afterwards 
taught that it had a miasmatic origin ; but if the first be a doubtful 
creed, the second is purely hypothetical : and we are free to look 
to the excessive, and as an elegant writer calls it, enormous vicissi- 
tudes of weather, irregularities and badness of food, and mental de- 
pression and anxiety, for the chief exciting causes of this fever. In 
a practical point of view, it more behoves us to know that, whatever 
may be the imputed origin of a fever, and its place in a nosological 
arrangement or a classification of diseases, it exhibits nearly the same 
organs for its seat, and functional disturbances for its symptoms; 
the difference being in degree but scarcely in kind. Hence, when we 
see a congestive fever, we find the same organs affected as in a com- 
mon intermittent and remittent; nor is there a notably organic dif- 
ference between congestive or malignant tertian and congestive 
typhus ; nor between these again and yellow fever, cholera morbus, 
epidemic cholera, and cholera infantum. The exposures during the 
invasion andactual attack of the patients to country air and town air; 
to a hot or a cold atmosphere ; and the differences in age, constitution, 
and prior mode of life, including, under this head, the ingesta, gesta 
and percepta, will give a modified physiognomy, by varying the ex- 
tent and intensity of the sympathies ; but the suffering organs are 
the same, and they are to be relieved by means nearly identical in 
all. On this account, at least under this belief. I deem it less neces- 
sary to enlarge on congestive typhus, in the manner in which it has 
been done by Armstrong, for example. Not that I would detract 
from the usefulness of many of his opinions as taught at the time. 
They have not been proved to be erroneous ; but, in place of their 
standing out alone in strong relief, they have been shown to be 
part of our general views on the subject of certain forms of all fevers, 
and, as such, to harmonize with them in the composition of a har- 
monious yet well defined group. In proof of the correctness of 
this assertion, it will be sufficient to refer you to the chapter of Dr. 
Armstrong's work, in which he gives the " History of the Different 
Forms of Congestive Typhus." You will, after reading his descrip- 
tions of cases, be struck with their close resemblance to those 
of the pernicious intermittents or congestive fevers of Rome, and 
of certain portions of our own country. Thus, as regards the 
symptoms, there was in the typhus, vertigo, chilliness, sickness and 
extreme weakness of the lower extremities, confusion of intellect 
and oppression of the praecordia. The countenance had a vacant 
and intoxicated expression ; the tongue was white in the middle. 



ARMSTRONG'S CASES. 



615 



smooth, and moist. To this state sometimes succeeded profound 
coma, with a pale and somewhat livid face, breathing deep and 
impeded; pulse small, frequent, and irregular; the skin dingy and 
partially damp, the heat of which felt nearly natural over the 
breast and belly, but the extremities were rather cold. " After the 
bowels had been well evacuated of much dark feces and bile," the 
stupor gradually disappeared, and some partial efforts of excitement 
succeed. In one case "his pulse and breathing became freer, his voice 
more natural, and his skin of a warmer glow ; but in contravention to 
these favourable symptoms, his hands were tremulous, his tongue 
fouler, and there were a few dark petechias scattered over the trunk 
and arms. Moderate portions of wine were now recommended 
at short intervals, with a view to support his strength ; but the 
debility increased under this plan, and he again sunk into a 
deep stupor, in which he expired, slightly convulsed, about forty 
hours from the first attack." This case furnishes an example 
of a comatose quotidian fever, in the second paroxysm of which 
the patient sank irrecoverably. In another case, after the par- 
tial efforts of excitement, subsequent to stupor, " there still ex- 
isted obvious disorder of the sensorium, evinced by a stupid fatuous 
stare; a slow, drawling mode of speaking, and much intellectual 
confusion. By degrees some petechias came out on different parts 
of the body, and the tongue grew foul and brown, the breathing 
laborious; the skin rather greasy, as well as cool; and the pulse 
considerably weaker and more rapid. Wine, cordials, and laxative 
medicines were now the principal means employed ; but they proved 
completely inefficient. On the third morning of the disease, imme- 
diately after a dark liquid stool, a general shivering supervened, 
like the cold fit of an ague, and life was soon terminated by suc- 
cessive attacks of strong convulsions." I need not say how closely 
this case resembles the comatose convulsive ones recorded by Dr. 
Eailly, and how appropriately, like those, it should be termed a 
malignant double tertian — the fatal paroxysm coming on in the 
third day. Dr. Armstrong would designate it by the term inter- 
mittent typhus. The analogy between it and our congestive is 
rendered still closer by the post mortem appearances described by 
Dr. Armstrong. In the subject of the first of the above fatal cases 
he discovered the vessels to be " loaded with blood along the convo- 
lutions of the brain ; and on deeper examination the whole cerebral 
substance was found preternaturally turgid, with some bloody 
serum in the lateral ventricles. The liver and spleen were likewise 
greatly distended with grumous blood, and the lungs had a gangre- 
! nous appearance in places." Had the author at that time paid 
I attention, as he subsequently did, to the minuter divisions of organ- 
ization by tissues, he would, we may suppose, not have left un- 
noticed the appearance of the arachnoid and of the gastro-intestinal 
mucous membrane. In another, and third case, although the 
symptoms did not correspond with those of the two first cases, 
" yet on dissection the morbid appearances were not very dissimilar; 



I 



616 CONGESTIVE TYPHUS. 

I 

for the brain, liver, and spleen, were the parts chiefly engorged with 
blood ; the two latter organs being ruptured by forcible pressure of j 
the hand." 

In the accuracy of the pathology of congestive typhus, as | 
explained by Dr. Armstrong, I have no reliance. Venous 
congestion and weakness of the right ventricle and imperfect 
oxygenation of blood, are causes of some symptoms, but they are, 
as I have already explained, effects also of prior and serious ; 
derangements of the nervous system. The treatment inculcated ', 
by this gentleman is very similar to that employed previously by 
Dr. Robert Jackson, viz., to immerse the patient up to his middle in 
a warm bath if the oppression was considerable ; then to bleed him 
from the arm ; and to empty the bowels freely by stimulating 
enemata, and purgatives of calomel and jalap. Venesection is only j 
proper, he thinks, in the first stage of congestive fever. In other 
cases of longer duration, leeches to the temples, or cups over the 
chest are to be substituted, and laxatives, enemata, and diluents 
used afterwards. Great stress is laid upon restoring the vitality 
and functional action of the skin ; and after the means above indi- 
cated, a large blister is to be applied over the region of the stomach 
and liver. Armstrong generally gave " a scruple of calomel at 
first, repeating much smaller doses three or four times on the first 
day of the attack, with the medicines above named ; and when the 
bowels have resisted their united action, saline purgatives were 
added, that no time might be lost." Elsewhere he states, " that 
after evacuations by bleeding or purging, an antimonial emetic 
often tends to produce a favourable change in the whole circulation." i 
In our country congestive fevers of quasi miasmatic origin, tartar 
emetic has not found favour with some judicious practitioners, nor 
ought it to be used in cases of extreme depression, and in the 1 
absence of symptoms of at least incipient reaction. But the pro- ; 
hibition of its employment thus early as an emetic does not con- j 
stitute an argument against its use as a simple counter-stimulus in 
the more advanced stages of the fever, or in the secondary conges- 
tive form, in which there is much capillary as well as nervous irri- 
tation combined. The partiality subsequently evinced by Arm- 1 
strong for calomel, pushed to the extent of producing ptyalism in 
congestive typhus, is not worthy of your imitation; founded, as ; 
the facts of the case are, in my opinion, on fallacious reasoning. 
A mercurial sore mouth is one of the symptoms of abated excite- 
ment; but its occurrence is not the cause of such abatement. A 
persistence in the use of calomel, when it has ceased to allay irri- 
tation, or when this latter subsides into a quiescence and sedation 
of function ; stupor, or somnolency ; cool skin ; small and frequent 
pulse ; has, I am sure, been often productive of the w T orst effects. 
Such a course contributes powerfully to the prostration of the sys- 
tem at a time when the physician is astonished that his large and 
repeated doses have no effect ; the only measure of effect, in his i 
mind, being the production of ptyalism. 



I 



SPONTANEOUS TERMINATION. 



617 



I will terminate the subject of the treatment of congestive fever 
by reminding you of a fact already stated, and which in practice 
you will have frequent occasion to verify. I refer now to the spon- 
taneous termination of fever after the completion of a stated period, 
without the administration of remedies, and, must we not add, 
sometimes in spite of them. The remarks of Cleghorn on this point 
were introduced at the conclusion of my last lecture on the pathology 
of congestive fever, and those of Valentin! at that of the one on typhous 
fever. Two cases of what the author terms remittent continued 
fever will serve to illustrate still more strongly the position now 
affirmed. The first is thus related by Dr. Tantini : 

On the 20th of August, 1811, there was brought to the hospital a young man, 
thirty years old, a field labourer, who had been at work for some days in the 
marshes. He was of a robust frame and healthy constitution. For six days 
past he has been afflicted with a continued remittent fever, of a malignant or 
nervous character. His condition, on his arrival, was as follows : fever with a 
morning remission, followed by an exacerbation of heat, which declined in a 
notable manner on the approach of night ; distress, great agitation at the be- 
ginning of the paroxysm ; skin hot till towards its decline, which was indicated 
by some moisture of the skin ; pulse weak, soft, and frequent, sometimes a little 
intermittent ; prostration of strength ; ideas confused and irregular ; slight delirium 
during the first few days of the fever; eyes bright; mouth dry ; tongue parched, 
and marked with a dark line in the middle; lips and teeth dry ; the chest and 
abdomen in a good state ; urine abundant ; alvine evacuations regular. 

I wished, says Dr. Tantini, " to make a trial of the camphor, proposed by Gua- 
rini, particularly in a case like this in which the pulse was soft. I added to it 
gum arabic, as in the following formula : Pounded gum camphor, a scruple : 
lumps of gum arabic, a drachm ; mint water, two ounces : and I directed a bottle 
of sweetened lemonade and half allowance. On the following day, that is, after 
the seventh accession, the patient had a copious sweat and a remission from fever, 
which never returned. After some days of convalescence he left the hospital 
well. 

The philopharmacologist might persuade himself that the camphor 
had brought about the crisis in the above case, which, in fact, had 
nearly reached its termination before the physician prescribed 
anything. In the next case, however, we have an example of the 
result which the unaided powers of nature will procure. The nar- 
rative runs thus : 

Remittent Continued Fever. — On the 26th of August, 1811, a young man, of 
about twenty-six years of age, who was of a somewhat more delicate habit than 
the subject of the preceding case, and who had worked for some days in the 
marshes, was brought to the hospital. He had a continued remittent fever ; the 
exacerbation of which came on at four o'clock in the afternoon, and was ushered 
in by increased heat followed by feelings of great prostration ; weak, soft and 
frequent pulse ; great restlessness at the beginning, and a slight perspiration at 
the decline of the paroxysm. The functions of the stomach and bowels were 
regular; the urine in small quantity and whitish; mouth dry, and tongue foul, 
I contented myself, continues Dr. Tantini, with directing emollient fomentations 
to the lower bowels, a mucilaginous enema, barley water for drink, and the half 
allowance. After the seventh accession he had, like the other patient, a copious 
sweat, and the fever entirely disappeared. 

After becoming acquainted with these and similar cases, one is 

53 



I 



618 CHOLERIC FEVER. 

tempted to ask the grave question — how much beyond the seventh 
paroxysm do we carry our feverish patients by our emetico-cathartic, 
mercurial, and stimulating remedies, which not seldom worry the di- 
gestive system and complicate the primary disorder of the nervous ? 



LECTURE IX. 

Application of the pathology of congestive fever to that of cholera in its various forms 
— Cholera infantum, outlines of treatment of. — Phlegmasia of the skin. — Different 
genera of— Hyperaemia — Exanthematae — Erysipelas, — its treatment. Roseola, — its 
varieties and treatment. Exanthematous or eruptive fevers proper — measles, scarla- 
tina, and small-pox — Their precursory fever and first eruption. Alleged differential 
diagnosis. Sequelae of eruptive fevers — Sameness of the organs affected in all of them 
— first, and chiefly, the air-passages ; then the digestive mucous and the serous mem- 
branes and the brain — Skin and pulmonary mucous membrane, the tissues which 
chiefly suffer — Treatment of the eruptive fevers — Must vary with the changing cha- 
racter of the epidemic visitation — Explanation of different modes of practice — that 
in the inflammatory scarlatina — Measures required in the congested and typhoid va- 
riety. 

Important, avowedly, as is the subject of congestive fever, I 
should not have occupied your attention so long on it if I had not 
been fully aware of the large circle of acute diseases, both the patho- 
logy and treatment of which are illustrated by a knowledge of its 
phenomena and progress. The same guiding principles which 1 
laid down in the preceding lectures will make you at once cognisant 
of the chief indications of cure in cholera in its various forms and 
stages. The depression of the nervous system and constriction of 
the capillaries, followed by a reaction in both, and these phenomena 
associated, from the beginning or in progress, with inflammation 
of some organ, are features common to all these diseases. In all, we 
should endeavour, at the outset, to soothe the nervous system, to relieve 
the irritation and congestion of the abdominal viscera by cooling and | 
sedative remedies applied to the digestive mucous membrane, and 
by mild stimulants and counter-irritants to the skin : in all, we should 
watch the reaction, and endeavour to ascertain how far it is simple 
neurosthenia, mere excitement of the nervous and vascular, and es- 
pecially the capillary system, and how far there is inflammation ; and 
then according to our diagnosis will be our directions for the abstrac- 
tion of blood in the paroxysm, and the administration of laxatives and 
enemata in the remission. In all, we shall find this last period 
justify and often imperatively require quinine. Thus, for example, 
if we take a case of cholera infantum, we bear in mind the irritation 
of the nervous system from high and continued heat, and the trans- 
mission of this irritation with various degrees of intensity to the 
vascular system, evidenced in augmented and morbid secretions, 
especially from the digestive canal ; which last is often quickened 
into morbid discharges by direct irritation applied to its mu- 



CHOLERA INFANTUM. 



619 



cons surface. The conditions for relief are simple, and con- 
sist in a removal of the irritants of the nervous system, and through 
it of the secretors. Cool air, or if this is not procurable, cool 
water to the skin ; simple food for the stomach ; occasional enemata 
to divert the action of the intestinal canal downwards, and 
sedatives in the form of small doses of opium, will often suffice 
for a cure. Reaction with the capillaries enlarged, and occasional 
gastritis or gastro-enteritis, may require a small bleeding from the 
arm, or the application of cups or leeches to the abdomen. Calomel 
in minute doses, an eighth, or a sixth of a grain, with a little simple 
mucilage, and sometimes chalk, is at times a good sedative agent; but, 
its effects in allaying the irritation of the stomach and bowels once pro- 
cured, it ought to be immediately and determinately desisted from. A 
cooler skin, or unequal temperature; extremities cold, and abdomen 
still hot, with a mouth and tongue less dry, are symptoms which will al- 
low of, if they do not indicate, the use of spirits of turpentine, warm pe- 
diluvia, and the warm bath ; as a stage a little earlier, marked by 
general capillary excitement and reaction, was benefited by the cold or 
cool affusion. A distinct remission of excitement, and a cold, often 
a damp or sodden skin, with or without increased intestinal dis- 
charges, will call for quinine, which now for several years I direct 
with the best effects in this advanced stage of cholera infantum. 
Unless by such means, or by country and cooler air, we can prolong 
convalescence, this state yields to a relapse with aggravated symp- 
toms ; among which, the most distressing are those of diseased 
brain — such as coma or somnolency alternating with restlessness 
and cries. Here we are tempted sometimes to bleed, as we almost 
invariably blister and sometimes stimulate powerfully, but all in 
vain. The brain does not suffer by congestion — it is in danger of 
effusion, which depletion must accelerate and stimulation will not 
cure. Opium and quinine, with moderate counter-irritation, are 
most to be relied on under such circumstances. Of the additional 
cause of irritation of the nervous system and consequent derange- 
ment of various functions, which depend on teething, as well as of the 
means of relief by cutting down to the tooth or teeth through the 
gums, I need hardly speak. This will occur to every physician. 
The necessity of preserving an equable action of the skin, and par- 
ticularly of the feet, by clothing adapted to the mutations of weather, 
ought to be equally obvious to all. It is one of the hygienic deduc- 
tions from the theory of congestion. 

But in a more especial manner is our knowledge of the eruptive 
fevers increased by an understanding of the theory of febrile con- 
gestion. Opportunity is not allowed for me to enlarge on this branch 
of my subject in the manner I could desire ; and I must be content, 
therefore, with stating the prominent points for your instruction. 
The order phlegmasia? of the class Diseases of the Skin have been 
divided into five genera ; — the first of these is the Exanthemata pro- 
per, including, under this head, erysipelas, roseola, rubeola ovmorbilli, 
scarlatina, and urticaria. The second genus is the Vesicular, in 
which we find miliaria, sudamina, varicella, eczema, herpes, and 



620 



ERUPTIVE FEVERS. 



psora. The third genus is Bullce, the species of which are pern- 
phigus and rupia. Genus fourth, Pustulce, has in it ecthyma, im- 
petigo, acne, mentagra, tinea, and variola and variolous eruptions. 
Genus fifth, the Papules, includes lichen and prurigo. Purpura 
comes under the head of hemorrhages of the skin, which constitutes 
the third order of the class. The first order, that preceding the 
exanthematous diseases, according to Andral, whose arrangement 
I now give, includes the Hyperce?nice, which embraces the three 
genera of active, passive, and mechanical. Hyperemia is simple 
increased fulness of capillary tissue, with often greater activity of 
nutrition. Erythema, the chief species of the genus of active hyper- 
emia, is characterized by red spots on the skin, of variable extent and 
appearance, and is produced by several causes; some external, as solar 
heat, hot or cold water, irritating substances, bites of certain insects, 
the secretion from mucous surfaces; others internal, as modifications 
of innervation, of which deep suffusion of the cheeks is an example, 
and derangements of the gastric function. There are persons who in- 
variably have erythema, which is sometimes called hives, on different 
parts of the cutaneous surface, in consequence of any mental emotion. 
In children it receives the names of tooth-rash and gum. Its duration 
varies from some hours and days to weeks. The treatment, which is 
commonly simple, will be modified by the causes producing the dis- 
ease and its complications. 

Some writers reject erysipelas from the exanthemata?, because it 
is not contagious, and may, as it does, recur frequently in the same 
person. Important in itself, its study is useful also by throwing light 
on the kind of connexion and the sympathetic action, direct and alter- 
nate, between the skin and the internal organs. Erysipelas is marked 
not only by redness, but also by a shining appearance of the skin, and 
pain, heat and tension of the teguments, accompanied, but not univer- 
sally, with fever. Though it may attack all parts of the skin, it most 
generally appears on the regions habitually uncovered, and hence 
erysipelas of the face is the most common. The causes of the dis- 
ease are external and internal ; and are the same with those which 
produce erythema, to which should be added the suppression of 
habitual discharges, and fatigue. Certain persons have a great pre- 
disposition to erysipelas, so that the slightest irritant — the common 
heat of the sun or of a fire will serve as a cause. On occasions, it 
seems to be under epidemic influence; and there are seasons 
when the smallest operation, or even scratch of the skin, particu- 
larly in hospitals, will give rise to the disease. Unlike erythema, 
which appears in different parts at the same time, erysipelas be- 
gins at one spot and gradually increases its surface — as when it 
spreads, for instance, from the hand up and over the arm as far as 
the shoulder. It must not be forgotten, however, that there is a va- 
riety of the disease called wandering, on account of its rapid change 
of place. I deem it needless to enumerate all the varieties of erysi- 
pelas, the chief of which are — 1, the phlegmonous, or that which 
includes subcutaneous tissues, and runs into a kind of suppuration if 
the inflammation is not checked; 2, the bullous or phlyctenoid, 



ERYSIPELAS. 



621 



in which the cuticle is raised into vesicles filled with serum ; this 
is an evidence of intense disease, and is most common when the 
face is the part attacked. The treatment in simple erysipelas con- 
sists in the use of diluent drinks, abstinence, and quiet. But when 
there are complications, and in every erysipelas of any degree of 
I intensity these may be expected, we must adopt a different and a more 
\ decided and bold course. If the fever runs high, particularly inerysi- 
I pelas of the face, there is danger of the brain suffering, and we are called 
! upon to bleed freely. Some have objected to blood-letting, because, 
say they, the erysipelatous eruption goes through its course without 
abbreviation by this remedy: but the important consideration is 
the suffering internal organ, and its protection from disorganizing 
inflammation. If, under an idea of erysipelas being a specific disease, 
which cannot be treated on the same principles with inflammation 
generally, the use of the lancet, or at any rate of leeches on the 
I sound skin near the affected parts, be omitted, the patient is very 
apt to be affected with prolonged and sometimes fatal stupor, which 
! is attributed to metastasis from the skin to the cerebral meninges. 
Where doubts exist of the propriety of venesection and of topical 
depletion, and at any rate as a proper preliminary measure, the ad- 
ministration of tartar emetic in lemonade wiil be found to be undoubt- 
edly efficacious. I have had opportunities of confirming the favour- 
able opinions of the utility of this medicine in erysipelas, so de- 
I cidedly expressed by such respectable authorities as Boyer, Andrai, 
and others. It may be given in a dose varying from the sixth to the 
fourth and even half of a grain, and repeated at intervals of three 
hours. The circumstance of the first and even second dose 
acting freely as an emetic will often be beneficial, nor will it inter- 
dict or render unnecessary a repetition of the medicine, which, 
should the excitement remain, will be subsequently tolerated by the 
stomach without inconvenience. But if at subsequent times it 
continue to cause vomiting, the dose must be reduced to the point 
of toleration. Blisters on the sound skin, yet close to the border of 
the erysipelatous part, were along time highly extolled as a means 
of arresting the farther progress of the inflammation. Lunar 
caustic applied at a short distance round the inflamed part has a 
similar effect. I have used blisters at times and with apparent 
advantage; at others, I have been disappointed in the benefit antici- 
pated from them ; and I am disposed to believe that the effect of 
their application depends very much on the degree of inflamma- 
tion or disturbance of the internal organ associated with that of the 
skin. The same remark applies to unguents, of which the mercu- 
rial was the first recommended, and subsequently the simple ones, 
directly on the diseased surface, under the allegation that mere 
grease was the active agent. Cloths dipped in fluid chloride of 
soda, or in a solution of chloride of lime, one drachm to the quart 
of water, are useful when applied to the part. After the stomach 
has been evacuated in the manner already stated, a mercurial purge 
should be administered; and then, if need be, the use of the tartar 

53* 



622 



ERUPTIVE FEVERS. 



emetic and acidulous drinks resumed. Stupor in a more advanced 
stage is to be treated with calomel followed by spirits of turpentine 
and oil ; or, if deglutition be impossible, active enemata of turpentine 
and oil, should be administered. 

Roseola is another non-contagious phlegmasia of the skin, 
which, independently of any intrinsic importance, merits at- 
tention on account of its being occasionally confounded with 
measles. Among its common names, are rash, rose-rash, and spuri- 
ous rubeola. -Its bright rosy hue, and hence its name, will serve to 
enable us to distinguish it from erythema. It is more common 
among women and children than men, and more in summer and 
autumn than at other seasons. The varieties of this exanthema are 
— 1. Roseola cestiva, which is sometimes preceded by a slight fever, 
and makes its appearance, first on the arms, face, and neck ; and in 
two days afterwards spreads over the rest of the body, producing a 
pricking and itching. It is exhibited with the appearance of small 
distinct spots ; large, paler, and more irregular than those of measles, 
and which are separated by numerous spaces, with the skin of a 
natural colour. At first red, they soon take a deep rose colour. 
The pharynx exhibits the same tint, and the patient experiences in 
swallowing a dryness and roughness of the throat which sometimes 
imposes on those around a belief of the case being one of scarlatina. 
On the second day the eruption is still at its height, after which it 
becomes duller ; but dark red spots remain on the fifth day, until 
which time the constitutional symptoms also persist. Occasionally 
the eruption comes and goes frequently after moral emotions, or 
seasoned food and stimulating drinks ; but sometimes without any 
evident cause. The retrocession of the exanthema is accompanied, 
usually, with gastric disorders, headache, and a state of languor and 
lassitude, which promptly disappear on the coming out of the erup- 
tion. This variety, as its name implies, appears most frequently in 
the summer in women of an irritable constitution, and is sometimes 
connected with the intestinal disorders of the season. It is inter- 
mediate between erythema and urticaria. The treatment consists 
in a restricted diet, acidulated drinks and at times laxatives. Pass- 
ing over the other varieties of R. annulata, autumnalis, vario- 
losa, vaccina, miliaris, febrilis, rheumatic a, and. cholerica, I shall 
say a few words on the roseola infantilis, which may be taken as the 
representative of the roseolous group. In this last variety the 
spots are more numerous and crowded than in the summer roseola; 
and when the eruption is general, if our diagnosis were to rest 
on its appearance alone, the case would be considered one of 
measles. It attacks children during dentition, or supervenes on 
intestinal and febrile disorders. Sometimes it only exists for a single 
night, or it appears and disappears for several days successively, 
accompanied by a derangement of the principal functions. The 
rheumatic roseola is occasionally a precursor of, and at times fol- 
lows, paroxysms of gout and rheumatism. That described by Dr. 
Schoenlein, consists of small, isolated, and rounded spots, of the 



ROSEOLA. 623 

j size of a millet-seed or a lentil, but rarely prominent, and it is of a deep 
J red or violet and sometimes dark colour. The fever ceases and 
I the rheumatic pains are abated so soon as this eruption shows 
I itself; as on the other hand its sudden retrocession by cold and 
! moisture, or by repelling applications, will cause a renewal and ag- 
j gravation of the pains. Other writers have described an eruptive 
epidemic rheumatism with fever. The treatment followed at 
j Wurtzburg consisted in the use of tartar emetic, if there was 
! gastric complication ; colchicum wine if the rheumatic pains were 
violent, and diaphoretics, such as the acetate of ammonia and 
! Dover's powder. The drinks are warm and demulcent : the regi- 
| men is simple and antiphlogistic. The choleric roseola was 
| observed by M. Rayer on the occasion of the epidemic cholera in 
! Paris, in 1832. It was more frequently seen on women than men, 
! and appeared most generally on the hands and arms, and extended 
j to the neck, chest, abdomen, and lower limbs. Sometimes the 
! eruption, when at its height, formed spots in tolerable approxima- 
j tion to each other, making a red tissue, like a slight scarlatina. 
In other places it would resemble measles and urticaria. M. Rayer 
saw this eruption complicated with inflammation of the pharynx 
and amygdalas, and its disappearance followed by an aggravation 
of the symptoms, and even death. Towards the sixth or seventh 
day the cuticle cracks, and falls off in large scales at the parts im- 
i plicated in the eruption. 

Of the exanthemata^ proper, in the preceding division, the 
two most important species, rubeola and scarlatina, yet remain 
to be noticed. But I shall not restrict myself so rigidly to the ar- 
rangement already adopted as to preclude me from speaking at 
the same time of variola or small-pox, which is often classed, to- 
gether with measles and scarlet fever, under the head of eruptive 
or exanthematous fevers. Believing, as I do, that these diseases have 
much in common ; and that a careful observation and study of 
the period of their invasion, and of the organ affected during the 
stage of eruption, and of their sequelae or organic lesions and disorders 
consequent on the first affection, will enable us to undertake their 
treatment on correct principles, you will find me laying more stress 
on these points than on this or that popular and plausible plan of cure, 
or last pretended specific. I feel the more encouraged to undertake 
| this task just now, (however imperfect and meagre it almost of 
\ necessity must be in its execution,) after my having enlarged so 
I fully on congestive fever, the pathology and treatment of which 
j is so analogous to those of the eruptive fevers ; especially 
| if these put on the form most calculated to alarm and embarrass 
I the practitioner. 

In nearly all the systematic works on internal pathology and the 
practice of medicine you will read the diagnosis of each of the 
I three great eruptive fevers. When these are fully established, the 
task is easy to distinguish small-pox from measles and scarlet fever ; 



j 



624 



ERUPTIVE FEVERS. 



and, though not so easy, to tell one from the other of the two 
latter. But I defy the most learned physician in diagnostics, if 
he is not swayed in his judgment by existing epidemic influences, 
the prevalence of a particular exanthema, and his know- 
ledge of the febrile diseases of an eruptive kind that his patient has 
had before, to predict positively, from the symptoms before him, 
during the period of invasion and anterior to the coming out of any 
eruption, what disease is in process of development — whether it is 
a remittent fever, or small-pox, — whether influenza, or measles, — 
infantile gastric remittent and verminose fever, or scarlatina. 
Equally difficult is it for him to say, from the precursory symptoms, 
which of the three eruptive fevers is about to reveal itself. You 
may be called to a young person who has had a chill, and whom 
you find, suffering from headache ; pain in the back and limbs ; in- 
tolerance of light and sound ; increased sensibility of touch, and to the 
impressions of heat or cold ; rigors with flushing, and gastric distress. 
You note, also, a tongue foul and loaded, and red at the borders ; heat 
of the abdomen ; urine high coloured ; skin dry and harsh, and of 
unequal temperature, though commonly more elevated than natural 
at the trunk and head, and below the standard at the extremities ; 
pulse frequent, and respiration hurried. If asked, what is the 
disease? you would naturally reply, a fever. But if the kind 
were demanded, you would feel yourself at a loss to name it. Let 
us suppose that, in addition to these symptoms, you discovered the 
pulse to be very frequent, or upwards of a hundred beats in a 
minute ; and that there are drowsiness and slight delirium, and a 
very offensive breath, with clammy mouth, and pungent heat of the 
skin ; — you might suspect that you had a case of incipient nervous 
fever. If, at the same time, you find redness of the fauces and 
tonsiis, and painful deglutition, you w r ill incline to the belief that the 
disease may be scarlet fever, — but it may, also, be small-pox 
or varioloid. I have seen nearly all these symptoms, except the 
delirium, precede an eruption of roseola. But you will be told that 
convulsions accompany the precursory fever of small-pox ; so they 
do, occasionally, that of the other eruptive fevers, — so they do, also, 
verminose fever and meningitis. Stress is laid by some on a severe 
pain or weakness of the back, so that the patient is all at once 
unable to support himself on his feet : but certain epidemical influ- 
enzas have been marked by precisely the same symptom. If your 
patient has been vaccinated, you will be inclined to narrow the 
diagnostic by excluding small-pox, and then determine which of the 
two remaining fevers, scarlatina or measles, is coming on. Should 
there be, however, measles and small-pox epidemic at the same time, 
your patient may be in the first stage of an attack of varioloid. Con- 
trary to d, priori belief, I have seen, and on this point I speak, for 
reasons soon to be given, from large experience, varioloid ushered 
in by a more violent initiatory fever, including delirium, than it 
ever fell to my lot to see in a case of small-pox. I speak now of a 
fact, and, without by any means affirming that it coincides with the 



PRECURSORY SYMPTOMS. 625 

! experience of others, or that it is a general one : I believe, indeed, that 

j it is not. Even for the first hours after the eruption has appeared, 

supposing your case to be one of an eruptive fever, you will still feel 

I somewhat at a loss in discovering the variety to which it belongs, 

j The skin of the face is deeply suffused, or erythernatic, and with 

• patches here and there of a darker shade, indicating eruption : over 

! the axillary and inguinal regions, on the sides of the chest and abdo- 

| men, there may be also patches of a red or crimson colour, encircled 

with minuter spots, and sometimes crops of maculas of a less decided 

| hue. Now it will be no easy matter to tell what precise form and 

i kind of eruption is to rise from this groundwork. All of this latter 
| is not the basis of eruption. Sometimes the maculas which came out 
j in a case of varioloid fever disappeared in a great measure : in 

small-pox they commonly represented papulas of a red and scarlet 
colour, which took their place, and constituted the first stage of 
| variolous eruption. But the small, red, and somewhat elevated 
spots, at the cutaneous follicles, in the early period of measles, are 
not easily distinguished from these papulae. Frequently in the Small- 
pox Hospital we had patients sent to us from the Almshouse In- 
firmary with a primary eruption which was supposed to be that of 
small-pox, but which, in fact, was rubeolous. The lapse of some 
hours between their entrance and our visit diminished, of course, 

ii the difficulty of the diagnosis, and gave us an opportunity, of which, 
however, I believe we did not take advantage, to express our sur- 
prise that the true disease had not been known to the medical 
inspectors of the other establishment. 

In pointing out the difficulty of diagnosis in the initiatory fever 
of the eruptive diseases, I do not, you may be sure, mean either to 
mystify you, or to discourage you from a careful and vigilant study 
of diagnosis in general, nor even in the circumstances before us. My 
aim is to show you the general community of organs whose func- 
tions are disturbed in all these fevers, as I hope soon to be able to 
show that this character of resemblance is maintained in the course 
of the disease, and is proved by the post mortem appearances. But 
whilst, with the modesty of true science you will frankly acknow- 
ledge to an anxious mother, or even to an impatient crone, that no 
one can say, from the symptoms during the first two or three days 
of fever antecedently to an eruption, what will be the precise 
variety of this latter, you must also have made yourself acquainted 
with the symptoms which are. at all entitled to help you towards a 
differential diagnosis. These I shall now state with all possible 
brevity. 

Measles is commonly indicated by symptoms of coryza and 
catarrh, in addition to those of a common febrile character : some- 
times the former are the only precursors, and we are left to suppose 
the coming on of a rubeolous fever by its epidemic prevalence, the 
age of the patient, and his not having had the disease. Under these 
circumstances, if the eyes be suffused and watery, the tarsi red, 
the eyes and nostrils discharging copiously a watery fluid ; and there 



C26 



ERUPTIVE FEVERS. 



are frequent sneezing, and a hard, dry cough, we may suspect that 
the patient is in the stage of precursory fever of measles. Hoarse- 
ness and weeping eyes I have, however, frequently seen to be pre- 
monitory symptoms of small-pox. Nor is the circumstance of 
difficult deglutition and soreness of throat diagnostic of the latter, 
since these symptoms sometimes are met with in measles, but less 
frequently than in small-pox. 

The period of incubation, as it is termed, or that which elapses 
between the reception of the contagion and the beginning of the 
disease, is said to differ with the kind of fever. In measles, this 
period is represented to be from twelve to fifteen days, although 
some make it ten, and after inoculation Home says six, and 
Willan sixteen days. The period of incubation of small-pox also 
varies from ten to twenty, and is fixed by some at eleven or twelve 
days ; whilst in scarlatina it is but four days. The eruption in 
small-pox takes place at from one to three days after the chill of the 
precursory fever, — generally it is on the third day, or after forty-eight 
hours ; in scarlatina the eruption shows itself on the second ; and in 
measles, on the fourth day. Often, the period of incubation is one 
of ailment ; the exposed person complaining of lassitude, want of 
appetite, disturbed sleep, &c. i but in other cases, again, there is 
hardly any deviation from the standard of health noticed before 
the beginning of the paroxysm of the initiatory fever. 

As regards the appearances of the eruption in the early stage, fitted 
to furnish materials for differential diagnosis, we can say that the 
papulee of small-pox are firmer than those of measles; and have a 
granular, hard feeling under the finger. But we are not left long 
in doubt as to the character of the eruption, if the case be one of 
Small-Pox ; as, then the papulee become more and more defined 
and elevated, and are, after a day or two, converted into vesicles, 
with small elevated centres or bodies of a yellowish-white, and 
more diffused red and somewhat hard bases or margins. The first 
erythematic blush which preceded the eruption had yielded with 
the distinct formation of the papulae : but now, as the vesicular erup- 
tion becomes copious, the redness of the margin extending, especially 
in the face, neck and hands, the skin becomes a red ground, from 
which project in relief the whitish vesicles. These latter become gra- 
dually larger, fuller, and more yellow, and filled with a thick, tena- 
cious matter. This last change is into pustules or the stage of ma- 
turation, which on the face begins at the fifth day and on the rest of 
the body in eight or nine days ; the early depression in the centre of 
the pustule is thought to be one of its diagnostic characters. The 
changes from papula to pustule arenotgone through at the same time 
in all parts of the body. I frequently saw, in the same patient and at 
the same time, the eruption to be papular on the legs, vesicular on the 
trunk and arms, and pustular on the face. Even one part, the arm, 
exhibited the three stages at the same time. About the eighth or 
ninth day, desiccation begins with a yellow dry point on the sum- 
mit of the pustule, although the suppurative stage may be said to 



SMALL-POX AND MEASLES. 



627 



j last to the twelfth day without any material change. At the date 
! of beginning desiccation, the body exhales that peculiar and un- 
I pleasant odour so readily recognisable after it has been once per- 
j ceived. But the eruption in small-pox is not confined to the face ; 
! it extends to the mouth, pharynx, and larynx; and I have seen it as 
! low down as the larger bronchia. Ptyalism is a common symptom 
! in the pustular stage. The febrile symptoms which abate during 
j the process of maturation are apt to return during desiccation, and 
■ when the skin begins to desquamate ; and they then constitute what is 
| called secondary fever. The skin, which had suffered so much, 
occasionally exhibits at this time an erysipelatous blush, accompa- 
! nied by an inflammation of the subjacent cellular tissue; and the 
formation of troublesome boils, or infiltration of serum, especially 
where there is much laxity of structure, as in the eyelids, lips, cheeks, 
&c. During the years 1823 and J824, I had ample opportunities 
j of seeing and treating small-pox, as it occurred in persons of dif- 
ferent ages, sexes, and colours, from infancy to adult life. The 
1 facilities given to me by my situation as Dispensary physician 
were still farther increased by my being associated with Dr. J. K. 
| Mitchell in attendance on the Small-pox Hospital at Bush Hill, and 
j subsequently at the old Sugar-House in the city. The results of 
I our observations and experience in variola and varioloid and in 
the protecting power of vaccination obtained during this period, 
are to be found in two papers prepared by me and published under 
our joint names in the North Amer. Med. and Surg. Journ., Vol.11. 
My references already made to hospital practice, and other obser- 
vations which I may still have occasion to make on the pathology 
of small-pox, induce me to advert to the sources of my experience on 
this subject. Still more in hospital than in private, and even Dis- 
pensary practice, had I an opportunity of witnessing the dangerous, 
and often fatal varieties of small-pox whichlhave described in the pa- 
pers just mentioned. There were the confluent, that which is common- 
ly contrasted with the regular and mild, or discreet eruption ; the ro- 
seate ; the tuberculous, and the erysipelatous. Drunkards among the 
men and prostitutes among the women, who were attacked with 
variola, rarely escaped death. The former had the roseate eruption ; 
the latter the confluent, on which dark spots, as if gangrenous, were a 
frequent appearance. Menorrhagia at any time in the course of the 
disease was a bad augury. 

Between scarlet fever and measles the differential diagnosis has 
been drawn out in detail by M. Rayer. Before borrowing from 
this description, I may mention that for a. long time the two diseases 
were confounded together ; scarlet fever being regarded as an aggra- 
vated form of measles until the time of Withering, and after him 
Willan. The eruption is of a deep scarlet colour, and hence 
the name given to the fever ; it appears on the second day of the 
fever, and is distributed at once nearly over the whole body in large 
confluent patches of undeterminate figure. That of measles comes 
out on the fourth day of the fever, in spots or rash, in a series 



628 



ERUPTIVE FEVERS. 



of crescents or imperfect circles, intersecting one another on the 
upper part of the trunk, and gradually extending to other parts : it 
is of a raspberry hue, and perceptible to the touch. The constitu- 
tional symptoms in measles are for the most part those of coryza 
and catarrh, with weeping eyes : in scarlatina the eyes are shining 
and inflamed ; the patient complains of sore throat. In scarlatina 
the eruption is not followed by an abatement of the fever, such as 
under similar circumstances occurs in measles. Desquamation in 
the first is by extensive laminae; in the second by branny scales. The 
secondary effects of measles are chiefly diseases of the pulmonary 
organs, — bronchitis, pneumonia, and sometimes phthisis. Scarlet 
fever leaves behind it often anasarca, inflammation of the serous mem- 
branes, and pustular formations in the joints ; and, as noticed by Dr. 
Graves, enlargement of the liver. Of the lesions of the organs of sense 
in the two diseases, ophthalmia is most common after measles, 
and otitis after scarlatina. According to Heim, the sense of smell 
will furnish us with still farther differences ; in scarlatina giving rise 
to an odour similar to that which we are sensible of in shops in 
which old cheese and herring are kept, or to that exhaled at some 
distance from the lodge of lions or other beasts of prey. This 
odour is perceptible from the beginning of the disease, and even 
before the appearance of the exanthema. Measles has also its pecu- 
liar odour, which is mild for the first week, and afterwards becomes 
somewhat more pungent : it resembles that of goose-feathers plucked 
freshly from a living animal, or one which has been recently killed. 
After all, however, I must again remark on the difficulty of diagnosis 
deduced from the sequelae of measles and scarlatina, or of these again 
contrasted with small-pox, which last is also followed by ophthal- 
mia, affections of the air passages and lungs, as well as irritability, 
if not positive disease, of the glandular system. Scarlatina may re- 
semble measles in its being followed by laryngitis and bronchitis, 
as both eruptions sometimes are by enteritis, and particularly of the 
larger intestines, manifested by dysentery and diarrhoea. 

One is less surprised at this general resemblance of functional 
disturbance after having learned that the same organs are shown, 
by post mortem examinations, to have been the seat of structural 
lesions in eruptive fevers, and this to a greater extent than might 
have been inferred during life. "In fatal cases of scarlet fever," 
Armstrong says, " you almost invariably find proofs of inflammation 
of the fauces extending down the larynx, trachea, and bronchia. 
In nine cases out of ten the air passages are inflamed." Strong as 
this language seems, its accuracy is borne out by the observations 
on the epidemic in Edinburgh, in 18e32, by Mr. Hamilton, a re- 
cord of which is in the Edinburgh Medical and Surgical 
Journal, vol. xxxix. He states that almost every severe case 
had more or less of the chest affection ; and he only met with one 
exception to the uniform extension in fatal cases of the inflamma- 
tion to the larynx, trachea, and lungs. The comparative frequency 
of inflammation of the mucous membrane of the bowels dwelt on 
by Armstrong, is not admitted to the same extent by other observers, 



ANATOMICAL LESIONS. 



629 



though the occasional presence of this lesion is undoubted. The 
same remark applies to the brain, which exhibits increased vascu- 
larity, with opacity of the arachnoid membrane and effusions of 
serous or turbid fluid between it and the pia mater. The kidneys 
might be supposed to exhibit organic alterations in those cases in 
which dropsy had existed before death and albuminous urine was dis- 
charged ; but Mr. Hamilton, who paid particular attention to the 
state of these organs, found in one case only the granular appear- 
ance indicative of what has been called Bright's disease. 

The intensity of the symptoms in the acute stage of measles 
leaves no doubt of the fact of inflammation of the air passages, and 
often of the lungs ; but we cannot speak so determinately on this 
point, as the deaths in this disease are more from its secondary 
affections. In the cases which terminate fatally, the marks of 
pulmonic alteration are generally clear, and next are those of inflam- 
mation of the bowels and brain. Mackintosh declares, that the 
lining membrane of the bronchia, trachea, and larynx, has not only 
been found in a highly vascular state, but it has been thickened, 
softened, and occasionally ulcerated ; the ulcers are small, and gener- 
ally situated near the bifurcation ; the bronchial tubes are more or 
less filled with a matter like pus or thick mucus, as in bronchitis. 

Almost identical with the appearances just described in subjects 
dead of measles, were those noticed in all the autopsic examina- 
tions which we made of persons who had died from small-pox, viz., 
great injection of the lining membrane of the larynx and trachea, 
varying in intensity from a deep red to a mahogany hue ; thick- 
ening of the tissue, and most generally ulcerations extending from 
the fauces to the larynx, and thence down into the bronchial bifur- 
cations, with abundant frothy mucus. The colour of the ulcerated 
spots was in some cases white, in others yellow. In one case, 
the subject of which died on the twenty-fifth day of disease and 
after desquamation had been nearly completed, the lining mem- 
brane of the larynx and trachea was of a greenish-yellow colour 
throughout, and in the spaces between the cartilages ulcerated and 
disorganized in several spots : chocolate-coloured liquor, with a 
sediment, filled the bronchia and the larger tracheal subdivisions. 
In the stomach I noticed injections of more or less extent, either of 
a roseate hue or brown, and sometimes bloody effusion surrounded 
by a vascular net-work ; the intestines exhibited similar appear- 
ances, but in a less degree and with less frequency. Enlargement 
of the mucous follicles in many cases might seem to the observer 
to be an eruption of the same nature as that on the skin. The lungs 
were sometimes healthy and at times inflamed, as was also the pleura, 
with effusion in its cavity. The pulmonary alterations, apart from 
those of the air passages, do not seem to be necessary effects of the 
variolous disease, but to be dependent on the season and prior ex- 
posure of the patient, either during the period of incubation, or during 
the secondary fever and after desquamation. On this point I used, 
in the communication already referred to, the following language : 

54 



630 



ERUPTIVE FEVERS. 



" It not unfrequently happened that persons who had passed through 
the different stages of the disease, and were advancing rapidly to 
convalescence, were suddenly seized with an affection of the chest, — 
pleurisy, hronchitis, or pneumonia, — and speedily carried off by the 
violence of the inflammation." 

A knowledge of the continuity of surface exposed to the air, and 
the close resemblance of the skin in structure and organic functions 
to the respiratory mucous membrane, would prepare us for seeing, 
without surprise, lesions of structure of the air passages in all the 
eruptive fevers. Are we able to deduce the treatment from the 
autopsic examinations, and the proofs of disorganizing inflamma- 
tion which they reveal ? Some physicians and writers, and they 
of authority too, have answered this question in an affirmative 
sense ; but, as I fear, with more boldness than accuracy. " Scarlet 
fever," says Armstrong, " is a disease which has been most success- 
fully treated in modern times. Formerly it was very fatal, and I 
am confident that the mortality arose from bad treatment." The 
contrast is meant here to be made in favour of depletion over stimu- 
lation. So, also, Mackintosh, who states that he saw many fatal 
cases when he practised according to the opinion of the schools, 
" carefully abstaining from blood-letting, and using all the means 
recommended to support the strength;" but he "occasionally ob- 
served patients snatched from the grave by considerable bleedings 
from the nose, and at times when it was thought the loss of an 
ounce of blood would prove destructive. These circumstances," 
continues the author, " together with the appearances found on dis- 
section, led me to bleed in many subsequent cases, and I have never 
had occasion to regret it." The practice, as advocated by these 
and other gentlemen, and as tried by myself at different times, 
was no doubt serviceable ; but its success is no proof of the 
error of other physicians in former epidemics, who adopted a dif- 
ferent plan of treatment; nor that those who coming after us do not 
imitate it, will be to blame. A better philosophy, based upon a large 
and impartial view of the facts of the case, teaches, that eruptive 
fevers, which in their worst form are of epidemic occurrence, vary, 
like other epidemics, not a little in the intensity of attack and 
danger at different periods. Scarlatina, measles, and small-pox 
too, sometimes assume an inflammatory, sometimes a congestive, 
and at others a more simple, yet prostrating or nervous type, in 
successive epidemic visitations ; as in the same epidemic they will 
manifest these distinguishing features in particular families and in- 
dividuals in preference to others. Dr. Graves, in lecturing on 
scarlatina, remarks, with his customary good sense, after speaking 
of the great mortality from scarlet fever in Dublin in the year 
1801-2, and of the subsequent occurrence, at intervals, of epidemic 
visitations, but always in a mild form, until the wide-spreading and 
destructive visitation of 1834-5 : " It was argued, that had the cases 
which proved fatal in 1801-2, been treated by copious depletion in 
their very commencement, the fatal debility would never have set 



TREATMENT OF SCARLET FEVER. 631 

in, for we all regarded this debility" as a mere consequence of 
previous excessive reaction. The experience derived from the 
present epidemic has completely refuted this reasoning, and has 
proved that, in spite of our boasted improvements, we have not been 
! more successful in 1834-5 than our predecessors in 1801-2." I 
j must confess — and I do so in the hope that others will be benefited by 
the acknowledgment — I entertained for several years no little confi- 
j dence in the value of the remedial means which I had recourse to 
! in the treatment of scarlet fever. Both in Dispensary and in private 
, practice I had a considerable number of. patients with this disease 
I under my care in different years ; and with hardly an exception the 
I, result was favourable. My practice, and it is the one which I am 
! still disposed to recommend to you in the inflammatory and anginose 
I variety of scarlet fever, consisted in keeping the patient in a room 
< well ventilated and without a fire, lying on a mattress and lightly 
■ covered : after the eruption was at its height, flannel, even if worn 
i next to the skin, was dispensed with until desquamation was in pro- 
! gress. Sometimes a mild emetic, and always a purgative, was ad- 
ministered ; and if the efflorescence and cutaneous heat were great 
and general, cold affusion was used: a temperature less high and dif- 
fused was met by tepid affusion. For the rules and practical details 
on the remedial effects of bathing in fevers and the exanthemata?, 
I refer you to my work on Baths and Mineral Waters. After the 
bowels were acted on, the neutral mixture, or acetate of potassa, with 
a portion of tartar emetic added in solution, was administered at 
suitable intervals. If the pulse was tense, and the evidences of deter- 
mination to the head and throat considerable, or much wakefulness 
and occasional delirium present, I had a small quantity of blood ta- 
ken from the arm, or leeches applied under the angle of the jaw, and 
on the skin corresponding with the region of the tonsils. Gargles, 
usually of a simple kind, were allowed towards the decline of the 
fever. The drinks were cold, and if the patient wished it acidu- 
lated ; the regimen was of the simplest kind. After the eruption 
began to decline, if there were restlessness, wakefulness, and dry 
skin, with a frequent and yet small pulse, Dover's powder in mode- 
rate doses, was given. In this way, and without being blistered or 
stimulated, my patients went through the disease with less suffering 
and to a more successful termination than I should have expected 
from the alexipharmic plan. I had several bad cases to encounter, 
too ; in one of two children, who were both grievously afflicted 
with the disease, there was a large abscess which burst and in- 
volved with it a loss of the teguments over the parotid gland, which, 
until the swelling had subsided and the matter was discharged, was, 
I thought, itself disorganized and lost. Both recovered. I have had 
three cases in one family sick at the same time, in two of which scarlet 
fever followed measles, and in one preceded the rubeolous fever : they 
all recovered. I thought, and I may be pardoned, perhaps, for my 
presumption, that I had the power of combating scarlatina wherever 
and whenever I met it, if I saw it in time, and the little patient was 



632 



ERUPTIVE FEVERS. 



not broken down by former disease. But I had yet to discover 
the other and darker parts of the picture, and to see my patients 
die notwithstanding all the resources of art; and worse again, 
after death I sometimes could not find a trace of organic lesion, 
notwithstanding the violence of the symptoms during life. 

As regards the probable cause of death in eruptive fevers, one is 
common and cannot be prevented : — I mean the loss of vitality ; at 
any rate, of functional action of the skin. Its secretion and absorption, 
fluid and gaseous, are both arrested : and as the pulmonary mucous 
membrane suffers in a similar manner, need we marvel that the dis- 
ease exhibits the appearance of virulent poisoning, in the production 
of which retained excreta in the blood and deterioration of this fluid 
must come in for a large share. The circulation is oppressed, the 
skin and mucous membranes are congested, and the nervous system 
is depressed and its properties perverted. To talk of inflammation 
in such a case gives no definite idea of the state of things, or guide 
for ameliorating it. Sometimes the disease is aggravated to agony : 
the skin becoming pale, at leasUosing the colour derived from the erup- 
tion, which last is then said to strike in. An effect of the concentrated 
irritation of the internal organs is here mistaken for a cause, — as if 
fainting were to be attributed to the cessation, or striking in, to use the 
popular phraseology, of a preceding, and, it may have been, intense 
blush. Though we may be afraid to bleed in such cases of great and 
alarming oppression, accompanied as it often is with coma, and 
constituting the worst or typhoid or malignant scarlatina, we are 
not, therefore, bound to stimulate. A simple abatement of internal 
visceral phlogosis by a cool drink, as of simple water, or a cold or 
tepid enema, has brought out the eruption, when hot-toddy, or wine 
and carbonate of ammonia, capsicum, &c, would not only fail to 
produce this effect, but would probably increase the violence of the 
symptoms. It is on this occasion that you will apply the principles 
which have guided us in the treatment of congestive fever ; and 
they will be found adapted to congestive measles and small-pox, as 
well as to malignant scarlatina. Thus, while you give cool and 
simple drinks with a few drops of laudanum inwardly; you apply 
warmth by means of water or vapour aided by friction externally ; 
you act through the stomach on the general system by a mild emetic ; 
and if this organ continue, or should become very irritable, without 
epigastric tenderness and thirst, you may suspect congestion, per- 
haps inflammation of the brain or its meninges, and address your 
remedies more especially to that organ. To do so, you direct 
leeches behind the mastoid process, a few in number and re- 
peated frequently, according to the urgency of the symptoms, so 
as to produce a more complete and gradual revulsion, — sinapisms 
at the same time being applied to the feet, or the lower limbs im- 
mersed in a hot mustard bath. If the fauces are red, and a sense 
of suffocation is present, you will leech with more freedom than 
when they are of a whitish or ash colour. The anginose variety 
of scarlatina will be more especially benefited by this leeching, 



RHEUMATISM.— ACUTE AND CHRONIC. 633 



which, in such cases, should always precede gargles. When these 
are necessary, you will select from the list the chloride of soda or of 
lime, muriatic acid diluted, lunar caustic, and alum. If you have 
cases in which there is a persistent inflammatory and open action, 
calomel may be used : in those of lower or typhoid action, spirits of 
turpentine. So soon as the first pressing symptoms in the malig- 
nant or typhoid scarlatina, which is sometimes congesto-inflamma- 
tory, sometimes congesto-nervous, are abated or removed by local 
blood-letting, evacuations from the stomach and bowels, and revul- 
sives to the skin, you ought to give the sulphate of quinine, either 
alone or in union with opium or the sulphate of morphia, according 
to the presence or absence of diarrhoea and the extent of nervous 
irritation. Of the internal medicines the list must be small: a 
weak solution of salines may be used with advantage, as already 
recommended in congestive fever. Fresh and cool air is to be 
continually introduced into the sick room. 

If in the progress of any of the eruptive fevers, inflammation of 
an organ arise, you must not allow any hypothetical notions respect- 
ing the modifying nature of the exanthematous poison to prevent your 
abating and removing it by the customary and appropriate means 
against phlogosis. In all these fevers, there isno little danger of sequelae 
occurring or being aggravated after desquamation is completed, or 
even in its progress, by exposure of the skin to a cold and moist air, 
and above all to currents of air. The clothing, however light during 
the fever, should now be ofsuitable texture, and abundant both day and 
night, in order to prevent a real catastrophe from such exposures. 



LECTURE X. 

Rheumatism, acute and chronic — Defined after the parts affected — Acute articular rheu- 
matism — Internal organs attacked — Symptoms of acute rheumatism — Is a true arthri- 
tis — Causes, exciting and predisposing — Congenital predisposition — Treatment, at 
first decidedly antiphlogistic — blood-letting, tartar emetic, colchicum, purgatives — 
Opium, when proper — Calomel most useful after an abatement of phlogosis — Its use 
not to be pushed so as to cause salivation — Warm-bath; opium; quinine — Acute 
rheumatism of the bowels — Pericarditis and endocarditis ; their frequency as varieties 
of rheumatism ; their symptoms. 

Rheumatism is divided into acute and chronic. The first is com- 
monly regarded as inflammatory; and to this view there is little 
practical objection : but more serious evils would follow in the 
belief that chronic rheumatism is always characterized, among other 
things, by an absence of inflammation ; whereas this form of the 
disease consists, at times, in a true chronic inflammation of the 
parts affected, or it may be simple neuralgia, or kept up by sym- 
pathy with derangements of the digestive apparatus and notably of the 
liver. Intermediate between the acute and chronic there is, occasion- 
ally, a stage which by some writers and lecturers is termed active, and 

54* 



034 



ACUTE RHEUMATISM. 



in which, with little fever, there is still considerable heat, swelling, and 
pain in the joints. You will have juster views of the character and pro- 
gress of rheumatism as well as a better guide to its treatment, by 
your learning the order of parts chiefly and primarily affected, 
on the lesions of which and functional disturbances ensuing, depend 
the features of the disease. In place, therefore, of calling it a dis- 
ease of the joints and muscles, distinguished by more or less inflam- 
mation of these organs and of associated fever, w r e should declare 
it to be either an inflammation in certain stages, or irritation in 
others, of portions of the fibrous, sero-fibrous, serous, and muscular 
tissues of the organs, both of locomotion and of sensation as well 
as of nutrition. 

I shall begin with Acute Rheumatism ; and my remarks will apply 
chiefly to the articular variety. Its first manifestations are the symp- 
toms common to the inception of all febrile diseases : rigors succeeded 
by flushing; accelerated pulse and thirst, but to which, in the case 
before us, are speedily added pain and tumefaction, with some red- 
ness and augmented heat of one or more of the larger joints — the 
ankles, knees, wrists, or elbows. These last are regarded as diag- 
nostic signs of rheumatism. Reduced to their proper value, they 
indicate a lesion of the synovial or serous capsule of the joint and 
of the contiguous and adjoining fibrous tissues. But simultaneously, 
or rapidly succeeding to or alternating with this state of the tissues 
of the joint, may be a similar one of those of internal organs, as the 
serous lining of the heart, or the endocardium, and the investing sero- 
fibrous membrane of this organ, or the pericardium ; the arachnoid 
and pia-mater of the brain ; the muscular coat of the alimentary 
canal, bladder, and uterus ; the diaphragm ; the muscles of the chest 
and abdomen; the pleura; and the sclerotica, the tunica albuginea, 
and the fibrous envelope of the kidneys ; the fibro-cellular sheath or 
neurilema of particular nerves ; and the aponeurotic investments and 
divisions of the muscles generally, but in a more particular manner 
of the voluntary ones ; finally, the ligaments of the spinal articula- 
tions and those termed sacro-iliac. Wherever fibrous and muscu- 
lar tissues are present rheumatism may make its attacks. 

The same cause or series ofcauses which produces acute rheumatism 
in the joints will give rise to this disease in any one or more of the 
tissues of the internal and other organs just enumerated. Com- 
monly, indeed, it happens that the latter comes on after the affection 
of the joints, sometimes, but rarely, by metastasis, or a complete 
transfer of morbid action from the one part to the other ; sometimes 
by more evident addition. But, on occasions, and they are more 
frequent than is believed, the internal organs will be primarily at- 
tacked, or at least the premonition, in some previous inflammation or 
tumefaction of a joint, will have been so slight as hardly to attract 
the notice of the physician, and was forgotten by the patient until he 
was carefully questioned in the matter. The practical inference 
from this view is, that in place of regarding rheumatism of the internal 
organs as anomalous, and to be driven to the joints, and thus reduced 
to its alleged true type, we ought to see in this affection of the in- 



SYMPTOMS OF RHEUMATISM. 635 

ternal organ a lesion of tissues, analogous to those which are the seat 
of acute articular rheumatism, and to be treated in the same manner 
as we would this latter. If there is a difference in our treatment 
it should be in the greater energy and promptitude of the means 
employed in internal than in external rheumatism. We shall, 
j after all, have more correct pathological notions on this head, 
. if we admit that inflammations of certain membranes, and 
I especially of serous, sero-fibrous, and fibrous ones, are frequently 
! induced by the same causes which give rise to acute articular 
I rheumatism ; and, as marked by many, it may be said most, of 
! the constitutional symptoms of this latter, they will require for their 
i removal a similarly energetic course of treatment to that which is 
practised for the external inflammation. 

Acute Articular Rheumatism, or Acute Arthritis, as it is some- 
times called, makes its attack in the manner already mentioned, 
j The subcutaneous veins of the affected joints are more dilated than 
usual, and are the more apparent owing to the skin being now 
stretched, thin, and shining. The pain of the joint is increased by 
the slighest motion, and even by touching it. Fluctuation, a sign of 
effusion into the cavity of the articulation, is only readily discover- 
able in the large joints, and especially in the knees, when the synovial 
membrane is the special seat of the morbid action. 

With the local symptoms are associated fever, the more violent 
the greater number of joints attacked, unless, indeed, the membranes 
of the heart are affected at the same time, in which case the in- 
tensity of the febrile symptoms does not bear a proportion to the extent 
of the articular inflammation. The pulse is strong, full, and hard, 
and in a state which is best designated by the term vibratory or jerk- 
ing: its beats are from a hundred to a hundred and twenty in a minute. 
There is much heat of the surface; little abated by abundant and 
somewhat clammy sweats of a stale, acescent, and nauseating odour, 
which often bathe the whole body ; but which are still more frequent 
on the face and neck. After some days' continuance of the sweat- 
ing, the skin, particularly where the perspired fluid has been most 
abundant, is covered with myriads of sudamina, which are 
often accompanied with a miliary eruption and red spots some- 
thing like roseola. Derangement of the digestive function is 
manifested by loss of appetite ; thirst often excessive and continued; 
constipation, and high-coloured and deficient urine. This fluid 
becomes muddy a short time after its evacuation, and looks like new 
or sweet wine, and reddens litmus paper. The tongue is whitish 
and clammy, as if powdered chalk had been sprinkled on it: as 
the disease advances, if the stomach be irritated and stimulating 
articles used, it assumes more of a reddish colour. The mind and 
senses generally, if we except that of touch in the skin of the affected 
joint, are but little affected. At times, however, and more par- 
ticularly with the evening exacerbation, there is some incoherency 
of thought and expression in the waking state, and disturbing 
dreams and mutterings during sleep. These last symptoms are 
more apt to occur if the patient have lived freely, or led a some- 



636 



ACUTE RHEUMATISM. 



what dissipated life, and has had his constitution enfeebled by this 
means. 

The blood drawn from the arm exhibits very speedily a firm and 
glutinous crassamentum covered by a bufFy coat, which I have seen 
in a case, recently under my care, to be fully half an inch in thick- 
ness. The coagulated portion floats in a clear yellow or green 
serum. If the former be inverted it has the form of a mushroom. 

Articular rheumatism, apart from its numerous complications 
with internal organs, shows itself with great variety, both in extent 
and intensity ; sometimes attacking but a few joints, such as the 
foot, hand, or knee; at other times invading all the joints: and as 
to intensity, it is sometimes so slight as to be dissipated in twenty- 
four hours ; and then again so severe as to last whole months, 
unless the most enegetic treatment has been employed. In no 
disease are there such rapid and frequent transfers of morbid ac- 
tion, or metastases, as in acute rheumatism : subsidence of pain and 
redness, and even of swelling of the wrist, for example, being 
speedily succeeded by similar phenomena in the knee or ankle; or 
a still more painful change, inflammation of the fibrous junctions 
of some of the spinal vertebras or of the sacro-iliac articulations, 
rendering the slightest attempt at movement exquisitely painful. 
An extension or transfer of the disease to the aponeuroses and 
cellulo-fibrous investments of the muscles, which constitutes, in fact, 
for the most part, that variety called improperly muscular rheuma- 
tism, is, also, attended by excessively augmented sensibility; so that 
the pressure, even of the bed-clothes, is intolerable, and the jar com- 
municated to the bed by a person walking heavily across the room 
is bitterly complained of by the suffering patient. In general, the 
fixedness and obstinacy of acute articular rheumatism are in the 
inverse ratio of the number of joints attacked ; and the readiness 
of transfer is diminished in proportion to the positive structural 
changes in a joint, as by effusion, thickening of the membranes, &c. 
The average duration of acute rheumatism is laid down at from 
forty to fifty days. The younger the age of the person attacked, 
the shorter, according to M. Chomel, is the period of his disease. 

That acute articular rheumatism is a true arthritis or inflamma- 
tion of the joints, is evident from the appearances and morbid products 
of the tissues affecterj. As rheumatism is not often directly fatal, 
the opportunities of determining this question are, happily, not pro- 
portionate to the cases of the disease. Enough has been noticed, how- 
ever, to assure us of the fact, that the fibrous and serous capsules 
of the joints are the parts which suffer most and primarily, and that 
they undergo, in persons who have died from other causes during or 
immediately afteran attack of rheumatism, thechanges characteristic 
of inflammation, such asthickeningofthe membranes, effusion of lymph 
into the cavity of the joint, and formation of pus. Alterations by en- 
largements of the ligamentsareof subsequentoccurrence, and in cases 
in which the disease assumes a chronic form. Instances are given 
by Bouillaud, some within his own observation, others collected 
from different practitioners, of pus having been found in the joints 



I 

CAUSES OF RHEUMATISM. 637 

which had been attacked with rheumatism, and also of partial de- 
struction of the articulating and fibro-cartilages. Mr. Cruveilhier, 

j in an article on Puerperal Rheumatism of the muscles and synovial 
membranes, reports three cases which ended in suppuration, and 
with removal of the articular surfaces. The tendency to suppura- 

I tion in rheumatism is said to be greater in puerperal females than 

\ in other persons. 

j Frequently as the muscles are represented to be the seats of 
i rheumatism, it very rarely happens that the muscular tissue proper 
, is subjected to structural changes. These take place in the inter- 
! posed cellular tissue and the investing aponeuroses of the muscles, 
causing, in the first, the formation of pus, and, in the second, the 
secretion of a sero-albuminous fluid. The one may terminate after 
a time as phlegmonous abscesses do; the other is extremely 
troublesome and hard to be cured. Notwithstanding the familiar 
reference to carditis and rheumatism of the heart in works of 
' medicine, the number of cases of this nature is very small indeed, 
! compared to the affections of the lining and investing membranes 
and of the valves of the heart. Dr. Williams, in his excellent lec- 
i tures on the Physiology and Diseases of the Chest, (published in the 
; Select Medical Library for 1839,) when speaking of carditis 
proper, or inflammation of the substance of the heart, admits that 
j he has not seen it, at least distinct from the membranous affec- 
1 tions. 

The causes of rheumatism are various ; but the chief one is exposure of the body 
to sudden vicissitudes of temperature, and more especially from a warm to a cold 
and moist air, and to the latter after the person has been greatly heated by exercise 
or labour. Much, however, of the susceptibility to be impressed in this way de- 
' pends on the constitution and habits of life of the individual. The young and 
robust of the male sex who are of a sanguine temperament, and in whom there is 
a sanguineous plethora ; they, also of the male sex, who have strained, as it were, 
the functions of life, whilst yet apparently in their prime and vigour, by the use 
of ardent spirits and stimulating ingesta, are the persons who most readily suffer 
in their health from the mutations of temperature and other atmospherical condi- 
tions, which are spoken of as the chief causes of rheumatism. It is not so much 
the activity of nutritive life generally, manifested in the deposition of cellular and 
I adipose tissue under the skin and between the muscles and around the viscera, as 
I of hematosis or the rapid formation and elaboration of blood with excess of fibrin by 
which the individual is rendered prone to rheumatism. Hence we often see persons 
of a spare habit of body, and who are far from being remarkable for their strength 
and muscular development, suffer as much from this disease as the athletic and 
j robust. A very slight irregularity in the functions of secretion and depuration, 
| induced by exposure to cold after the body is heated, will suffice in these cases to 
' determine the blood to the fibrous tissues, and make it a stimulant in excess, 
j Some of the persons, with this susceptibility, will have common inflammatory 
fever, — others acute rheumatism or rheumatic fever, according to the season, and 
! their subjection to occasional and predisposing causes. At times, cold and mois- 
I ture are the predisposing causes, and a sudden and violent exertion or strain upon 
a particular part is the exciting cause ; as when the effort to pull on a tight boot 
j gives rise to lumbago. The susceptibility, again, is created by prior irritation in 
a part, as in the joints of the lower limbs by a long march, in the alimentary canal 
by the frequent use of drastic purgatives, in the kidneys and bladder by the use 
of fermented and distilled liquors and highly azotised food. 

The atmospherical alternations and vicissitudes, so manifest and sensible in 
spring, are recognised causes of rheumatism in common with those of pleurisy, — 



638 



ACUTE RHEUMATISM. 



whilst analogous changes, together with the prevalence of easterly winds and a 
still more abundant moisture, place the former on a line with fevers of alleged 
miasmatic origin ; and hence it is no uncommon thing to find violent pains in the 
fibrous tissues, as well tendinous as aponeurotic, to alternate with or themselves 
assume the type of periodical fevers. 

Much stress has been deservedly laid by some writers, MM. 
Roche and Andral, for example, on a predisposition to rheumatism, 
which, in addition to the states of the system already mentioned, 
consists in great sensibility of the skin and an especial activity of 
the capillaries of this part. It is increased after each attack, so 
that the person who has often suffered in this way will have a re- 
turn of the disease from the slightest causes, as any error of regimen, 
the changes of season, and other variations of temperature. Here- 
ditary predisposition is not without its force in many persons who 
are frequent and early victims to rheumatism. 

Among the causes depending on prior alterations in the state of 
the body itself, are the disappearance of a cutaneous affection, the 
sudden drying up of an issue, or of the hemorrhoidal or menstrual 
discharges; blows and falls ; protracted use of mercury. If the 
influence of this last cause be admitted, its operation is more evident 
in the production of chronic than of acute rheumatism. An im- 
minent predisposition to this disease is manifested by the urine 
being deeply reddened, and by its depositing a red sediment. 
Another sign is a zone of vessels of a light pink colour surrounding 
the cornea, and often discernible, especially during the prevalence 
of northerly and easterly winds. 

Treatment. The age and sanguineous plethora of the patient at- 
tacked with acute articular rheumatism ; the frequent and hard pulse, 
hot skin, violent pain, redness and swelling of the affected joint or 
joints, and the diminished secretions, would seem to indicate at once 
the propriety of venesection. General experience sanctions this prac- 
tice, which, in order to be fully serviceable, ought to be early resorted 
to, and in such a measure as shall produce a decided impression on 
the general system as well as an abatement of the local inflamma- 
tion. From sixteen to thirty ounces of blood, according to the 
vigour of the patient and intensity of the disease, may be taken 
from the arm at once ; and if the distress and pain continue, or 
are soon renewed, the bleeding should be repeated to an extent 
commensurate with the urgency of the case and the degree of 
toleration by the patient of the first evacuation. They who, with 
M. Andral, allege that the blood in a rheumatic subject is not only 
in excess, but also that it is too stimulating by its over-abundant 
quantity of fibrin, will find additional motives for a diminution, by 
venesection, of the amount of a fluid which, through the medium 
of the capillaries, morbidly excites all the tissues, and notably at 
this time the fibrous, the sero-fibrous, the synovial, and the mus- 
cular. The appearance of the blood drawn, consisting as it does 
in such large proportion of a dense and tenacious coagulum, and ex- 
hibiting a buffy coat of great thickness, would seem to justify the 
wisdom of the treatment. But, although it is one of the elements in 
our calculation of the intensity of the disease and of the parts affected, 



TREATMENT OF RHEUMATISM. 



639 



we are not to lay undue stress upon this appearance, and we must re- 
member that, in some cases of rheumatic fever, nothing short of an 
entire renewal of the circulating mass would be followed by an 
absence of buff on the surface of the blood drawn. It is, how- 
ever, not the less clear that, in this first stage of acute rheumatism, 
whether we regard the state of the heart and blood-vessels, even 
though we may not believe them to be the seat of phlogosis, or the 
quantity and quality of the blood circulating in them, the vascular 
system has the ascendency, and by its morbid change gives its 
features to the disease. Hence, so long as these features persist 
unchanged, so long, without a very nice reference to the number 
of days which have elapsed since the disease began, or to the prior 
frequency of venesection, ought we to persist in the practice of this 
latter. If the inflammation of the joints should continue after an 
abatement of the morbid excitement of the heart, which is to be 
measured, as well by auscultation and percussion over this organ, 
as by the state of the pulse, cups in the vicinity of the inflamed 
part, or leeches directly over it, will often contribute to the end pro- 
posed. When the pains shift rapidly from joint to joint, and from 
the upper to the lower extremities, or contrary wise, cupping on 
each side of the spinal ridge, in lines extending from the cervical 
to the lumbar vertebra?, will be followed by manifest relief. Auxil- 
iary to blood-letting, but seldom adequate substitutes for it, will be 
the administration of mercurial followed by saline purgatives, 
and afterwards of tartar emetic. This last is to be begun in a sixth 
and increased to a fourth, and soon afterwards to half of a grain 
every two hours. The physician who has not made trial of the 
antimony in this manner, with a view to its directly antiphlogistic 
or counter-stimulating operation, irrespective of and even unac- 
companied by evacuations, either of vomiting, purging or sweating, 
will be agreeably surprised at its effects, and the extent to which 
the stomach will tolerate it, so long as vascular excitement is main- 
tained. It is more especially in inflammation of the fibrous or 
serous system, or in acute articular rheumatism and pleurisy, that 
I hold tartar emetic, given in large doses frequently repeated, to be 
a valuable therapeutical aid. The time for wonderment at the pos- 
sibility of the patient being able to take full and repeated doses of 
this medicine without its vomiting him, and of speculative doubts 
or objections from analogy as to the safety of the practice, is now 
past. Experience in the Italian, Swiss, and French hospitals, and in 
private practice, is so conclusive as to show that, with the precau- 
tions always required in the administration of a remedy of any ac- 
tivity, tartar emetic may be not only safely, but very advantage- 
ously given in various phlegmasia?, as auxiliary to the use of the 
lancet; and in cases where doubts exists as to the propriety of the 
latter it will take its place. 

With the same view by which we are guided in having recourse 
to tartar emetic, we may also use the colchicum in acute rheuma- 
tism, either alone or in combination with the first named medicine. 
The preparation with which I am most familiar is the vinous tine- 



640 



ACUTE RHEUMATISM. 



ture of the seeds, which I give at first in a dose of a drachm or two 
drachms with magnesia or salts, in order to produce an early and 
marked impression ; or I add to a drachm of the wine of colchicum 
seeds a grain or two, as the case may be, of tartar emetic, dissolved 
in four ounces of camphor water with some sugar, and direct a 1 
tablespoonful every two hours. The effects of this combination, 
thus administered, are — general perspiration ; at times purging 
without griping ; and a decided abatement of the pain and fever. 
The action on the skin is still more evident, if twenty to thirt}^ 
drops of laudanum have been added to the mixture. Earlier re- 
course may be had to opium when thus combined, than either alone 
or in any other form. But you must be prepared to find the sto- 
mach more and deeply affected by large doses or the protracted use 
of the colchicum, than by tartar emetic. Hence you will be re- 
quired to exercise vigilance in watching the operation of the former, 
and withholding it when it begins to display its poisonous effects; such 
as frequent vomiting, and purging of mere watery fluid ; deep felt 
distress and anxiety, chiefly due to the powerful impression of the 
drug on the sympathetic nerve ; and great feebleness of the volun- 
tary muscular system. The acetum colchici is also much used in 
this disease ; and more recently, the acetic extract, in a dose of 
half a grain gradually increased to two grains. 

Opium, always a favourite remedy in rheumatism of every form, 
has been recently, on the strength of Dr. Cazenave's experience in 
its favour, used by Dr. Webb of Providence, in a dose of one grain 
every two hours, until " hilarity" and " perspiration" are induced ; 
and then in the same dose every two hours, and afterwards a dimi- 
nution of dose and increase of interval. In one case forty-two grains 
were taken in fifty-four hours ; in another, sixteen grains in the 
same number of hours. Sometimes VS. and purging had been pre- 
mised, at other times not. Ptyalism and purging were occasional 
effects of the opium. — {Boston Med. and Surg. Journ., Vol. XVI.) 
Dr. Carregan, of Dublin, gives similar testimony in favour of the 
opium practice in acute rheumatism. He has prescribed seven or 
eight grains in a day. Small doses are said to increase the fever 
and restlessness. My own belief, however, still is, that in rheuma- 
tism and in the phlegmasia generally, so long as the vascular 
system maintains its disproportionate ascendency, as manifested by 
the chief symptoms and secondary changes, which are the result 
of its morbid state and action, little good can be expected from 
the use of opium or of any of the narcotics. 

Purgatives may well alternate with the use of colchicum and 
antimony, and their repetition will be indicated by the appearance 
of the tongue, and the discharges being fetid and slimy. Calomel 
and jalap, or calomel with the compound extract of colocynth, will 
answer in these cases. 

Under the circumstance in which, although vascular excitement 
is in a measure controlled, yet the articular inflammation and pain, 
and general disturbance and anxiety still remain, mercury is recom- 
mended as an almost certain means of relief. Dr. Hamilton of 



CALOMEL, — TIME FOR ITS USE. 641 

Lynn, who, in England at least, has contributed the most, by his 
published opinions, to the free use of calomel in rheumatism, took 
care to precede it by venesection, and to conjoin with it saline 
medicines and antimony ; all of them agents of power in subduing 
the disease. That mercury has a repressive and even curative 

j operation in inflammations generally, as alleged by Hamilton, I 
have already shown : but there is, it has always seemed to me, a 
great difference in its power, in this respect, over the different tissues ; 

j the mucous membranes of all the organs and the glands which 
open on the former and are in a measure subservient to their wants, 

j being much more impressible than the serous and fibrous mem- 
branes. Hence our success in the use of mercury in hepatitis will 

| not afford a measure of similar success in idiopathic arthritis or 

I articular rheumatism, — nor its efficacy in bronchitis be an index 
to its use in pleurisy. But although experience is, we learn, deci- 

| sively in favour of calomel, especially when conjoined with opium 
and antimony, in acute rheumatism, yet we are bound to protest 

[ against the empiricism which can lay down no other measure of 
its adequate exhibition and full effect on the constitution than by 

j its affecting the salivary glands to the extent of incipient ptyalism. 
If the use of calomel in rheumatism be followed by a softer pulse, 
a moist and soft skin, a discharge of urine with abundant sedi- 
ment, and an abatement of the pain of the joints, we have both 

I reason and encouragement for continuing its use ; but, at the same 
time, we ought steadily to deprecate that extent of mercurial action, 
or of mercurial disease being set up in the system, the measure of 
which is ptyalism alone. There is a stronger reason against excess 
in the case of mercury than in that of any other medicine in common 
use, if we except arsenic ; on account of the pains in the fibrous 
and muscular systems w T hich follow abuse of this kind, and which 
simulate so closely certain forms of chronic rheumatism as to be 
often confounded with these latter, as both of them, again, have 
been with secondary syphilis. Your patient will, therefore, have 
small cause for gratitude to his physician, if, in exchange for 

I an acute pain of limited duration, he be tormented afterwards for 

: years, at irregular intervals and yet for long periods, with a more 
mitigated but still harassing pain ; and be, withal, more liable to 
suffer from those atmospherical influences which induce a return 
of the acute form of rheumatism. 

I believe that we shall do better to abstain from calomel, or 
other preparation of mercury, except as a purge, or from mercury 

I and opium, in the early days of the first stage of acute rheumatism ; 

I and to wait until vascular excitement is somewhat reduced. When 

i the inflammatory condition is about to yield to the irritative ; 

| when capillary is more evident than cardiac excitement; or when 
the sub-acute, or as some writers call it, the active stage, has 

! arrived, calomel or blue mass may, if necessary, be had recourse 

! to, either alone, or in conjunction with opium. If, indeed, the 
nervous has succeeded to the ascendency of the vascular system ; 

55 



642 



ACUTE RHEUMATISM. 



and pain, restlessness, and wakefulness with simple irritability and a 
dry skin have replaced a hot or clammy skin, a hard pulse, flushed 
cheeks, and great thirst ; then may opium alone, or with ipecacu- 
anha or antimony, or even with minute doses of colchicum, be 
directed with great benefit for the time, and more safely to 
the patient than the.so-highly praised combination of calomel and 
opium. 

It is in this stage of the disease that the warm water or warm air bath, 
sponging of the surface, and the moist vapour bath, will conduce, in 
addition to the above remedies, to a restoration of the natural state of 
the skin, and through it of the internal secretions, and at the same 
time contribute to remove the remains of inflammation and asso- 
ciated stiffening of the joints. 

Now, also, is the time for the administration of quinine or some 
other preparation of the bark. Little as I can doubt the powers 
of observation and fidelity of narrative of so many English practi- 
tioners who have lauded the bark in rheumatism from the very 
beginning of the disease, I cannot abandon my own convictions of 
its inapplicableness to the acute stage, such as we find it in the class 
of subjects, young, sanguine, and plethoric, who are its chief victims. 
But when this stage is passed, and the patient is enfeebled, sweats 
excessively, and is still unable to move his limbs without suffering 
extreme pain, quinine should be had recourse to as a means of com- 
pleting the recovery, rather than as necessary repressive of the 
primary intensity of the malady. More especially will it be useful 
in cases strictly paroxysmal and which exhibit tolerably dis- 
tinct intervals of ease from pain. We need not wait, whether we 
have to deal with common articular rheumatism or that variety 
in which the sclerotic coat of the eye is so severely affected, until 
the yet injected and sensitive, though no longer inflamed mem- 
branes, have resumed their natural colour and appearance. This 
resumption will be often expedited, and the general system strength- 
ened by the use of the quinine — provided, as already stated, that the 
intensity of the inflammation be subdued, that the tissues of the 
internal organs are not the seat of acute disease, and that the diges- 
tive canal be neither phlogosed nor loaded by feculent or fetid 
matter. 

It rarely happens that we are forbidden to combine opium with 
quinine when the stage is reached in which this latter is admissi- 
ble; and there are often good reasons in the vigilance and restless- 
ness, indicated by the common yet vague term nervousness, which 
will render such a combination very useful. 

Reference has been already made to the frequency of metastasis 
of rheumatism, not only from one joint to another but from the 
joints to internal organs, especially the heart. We must also be 
prepared to meet with rheumatic affections of this organ, or more 
specifically of its investing membrane, constituting pericarditis, and 
of its lining membrane, causing endocarditis, after a very slight pre- 
monition from common articular rheumatism. A similar remark will 
apply to the occurrence of acute rheumatism of the muscular coat 



PERICARDITIS AND ENDOCARDITIS. 



643 



of the intestines, which is frequently mistaken for colic, but which 
I differs from this latter in its being accompanied by a tense, resisting, 
j pulse, greater heat of the skin generally, a craving for cold drinks, 
I and the persistence of the pain and sympathetic distress in other 
I organs, even after the bowels have been freely evacuated of their 
j contents. 

The treatment of acute rheumatism of the bowels, called by some of the older 
| writers rheumatic colic, will not differ from that already laid down for acute 
j articular rheumatism. The use of the lancet is strongly required in the first as 
we have seen it to be in the second case, although we must not expect to find the 
blood drawn in the one exhibit so much, or so uniformly, a buffed coat as in the 
other. Even in the disease before us, in which opium seems to be so urgently 
called for to j allay the excessive pain of the bowels, we shall be often disap- 
pointed if we have early recourse to it, or believe that it can be used, either alone 
I or in combination with calomel, in place of the lancet. To venesection may ad- 
vantageously succeed the application of cups or leeches over the abdomen, fol- 
lowed by fomentations and, if need be, blisters; although these will disappoint us 
| if had recourse to at an early date. Vesication being established, morphia may 
1 be applied to the denuded skin with occasionally good effect — a kind of medica- 
! tion not without its value in the commoner forms of rheumatism in the sub-acute 
stage. In this case the cuticle had better be removed to a small extent over 
the upper part of the spine and the morphia sprinkled on the exposed skin. 

Pericarditis and Endocarditis of a rheumatic character may 
occur primarily in one person from the same causes which in another 
would give rise to articular rheumatism, or they may be the conse-i 
quence of metastasis ; or, finally, the sequelae of the articular variety, 
as well as of rheumatism in other parts. 

M. Bouillaud, who has paid most attention to pericarditis and 
endocarditis, as connected with articular rheumatism, asserts 
that in eight cases out of nine the latter affection is accompanied 
by the former. In another estimate made by this writer the pro- 
portion is not so great ; out of ninety-two cases recorded by him, 
there were thirty-one in which pericarditis and endocarditis coin- 
cided with articular rheumatism; viz., seventeen of pericarditis 
and fourteen of endocarditis. 

The existence of pericarditis, is believed, by M. Bouillaud, to be 
certain in the individual affected with rheumatism when the fol- 
lowing symptoms are present : a dull sound, on percussion, over 
the precordial region, on a surface double and triple the extent of 
that in health ; arching or elevation of the same region ; remote beat- 
ings of the heart, but which are little or not. at all sensible to the 
touch; sounds of the heart distant and obscure, and accompanied 
by different abnormal sounds, some arising from the rubbing of the 

j opposite coats of the pericardium against each other, others from 
the complication of pericarditis with valvular endocarditis ; and a 
pain more or less acute at the region of the heart. Palpitations, ir- 

| regularities, inequalities, and intermissions of pulse, are sometimes 
conjoined with the above symptoms. 

The coincidence of endocarditis with acute articular rheumatism 

! is, on the same authority, certain when the following signs are pre- 
sent: bellows, file or saw sound in theprecordial region, with a dulness 
of this part on percussion, to an extent much more considerable than 

I 



644 



ACUTE RHEUMATISM. 



that in the normal state, and also sometimes, but in a less degree 
than in pericarditis with effusion, an elevation or abnormal arch- 
ing of the chest : the movements of the heart raise with some force 
the precordial region ; and these are often irregular, unequal, inter- 
mittent, and accompanied, at times, with a vibration and trembling. 
The pulse is hard, strong, vibrating, unequal and intermittent, like 
the beatings of the heart.* 

It may not be amiss, in this place, to point out the distinction 
between a simple modification of physiological or dynamic action, 
and a lesion of structure, so that the former, as presented to us in pal- 
pitations, intermissions of pulse, and in the beating of the heart, and 
other irregularities, simply nervous, may not be mistaken for or- 
ganic lesions. Careful auscultation and percussion are the means 
of diagnosis, and will enable us to declare that even pains, as well 
as palpitations and intermission of ventricular contraction, with or 
without a tendency to syncope, oppression, &c, are not evidences 
of either pericarditis or endocarditis, unless the permanent bellows, 
saw, or file sound be heard. 

Doctor Williams corroborates the views of M. Bouillaud in re- 
gard to rheumatism being by far the most common cause of peri- 
carditis, adding, "but it still more frequently produces endocarditis;'' 
and although he does not think these inflammations are essentially a 
part of rheumatism, he can confidently state that he has found signs 
of endocarditis or pericarditis, or both, to a greater or less extent, 
in fully three-fourths of the cases of the disease in question. He 
adds, that in a little more than half of the proportion just stated, there 
was there no complaint of pain in the chest, palpitation, or dyspnoea. 

Dr. Macleod {Med. Gaz. 1837-8.) makes the proportion one-fifth. 
I must content myself at present with having directed your atten- 
tion to this new and highly important feature in rheumatism,— the 
connexion and alternation of inflammation between the sero-fibrous 
membranes of the heart and the analogous ones of the joints. I had 
prepared the details and descriptions, with the intention of introducing 
them to your attention at this time, of the physical and other signs of 
pericarditis and endocarditis ; but the necessity just now of compres- 
sion short of obscurity interferes with my intention. Having opened 
the subject, it remains for you to prosecute the inquiries for its elucida- 
tion, which you will find easy by a reference to the w r orks already 
mentioned of Drs. Williams and Bouillaud, and to the last edition of 
the valuable Treatise on the Diseases of the Heart by Dr. Hope. 

Contrary to the opinion advanced by Corvisart and others, both 
M. Bouillaud and Dr. Williams agree in believing that pericarditis 
is not by any means a fatal disease; and the same, with some quali- 
fications, is said by the first of these two writers, of endocarditis. I 
have met with but few cases, says the English writer just named, 
of pericarditis, which first attacks a sound heart, proving fatal in 
its acute or chronic form ; but I have known several, who, partially 
or apparently, recovered from a first attack, after some months or 

* New researches in Acute Articular Rheumatism, in general. Translated by 
Dr. Kitchen, and published in the Select Medical Library for 1837. 



TREATMENT OF PERICARDITIS, ETC. 



645 



even years exhibit signs of organic disease of the heart, and ulti- 
mately sink under a subsequent attack of pericarditis supervening 
on this. The average duration of the disease, when judiciously and 
successfully treated, may be estimated at from seven to fourteen 
days. Very violent cases of it may, however, prove fatal in little 
more than twenty-four hours. Those originating in rheumatism 
are generally the most obstinate. 

Endocarditis is induced by the same kind of causes as pericar- 
ditis. It may occur either as a primitive or as a consecutive 
disease. The affections on which it is most apt to supervene are, 
pericarditis, pleurisy, phlebitis, and acute rheumatism. In the acute 
stage it may terminate fatally in a very few days ; and one of the 
principal causes of death here is supposed to be the extensive for- 
mation of sanguineous concretions within the heart. If actively 
and properly treated it will generally end favourably within about 
a week; but if it pass into the chronic state, its duration is inde- 
finite. Yet even here the lesions thus produced become sometimes 
apparently stationary, and under judicious management life may be 
prolonged to a very advanced period.* We ought not, however, 
to be unmindful of the following remarks of M. Bouillaud in his 
work on acute articular rheumatism already noticed. " If it be 
true that acute inflammatory affections of the heart are much less 
fatal than has been supposed, it is but too true, at the same time, 
that, persisting, they ordinarily leave in their train lesions called 
organic, under which the invalid finally sinks, when they affect 
those parts whose functions are necessary to life. This is what ac- 
tually takes place when endocarditis has been followed by thickening, 
induration, adhesions, vegetation of the valves with deformity, oblit- 
erations of these valves, contractions of the orifices, dilatations of the 
cavities, hypertrophy of the muscular substance," &c. I shall speak 
of the practice to be pursued in these diseases in my next lecture. 



LECTURE XI. 

The treatment of pericarditis and endocarditis — Other varieties of the disease ; pleuro- 
dynia, diaphragmitis, &c. — Regimen — Chronic Rheumatism — Same order of parts 
affected, and similar morbid products as in the acute forms — Two divisions, the active 
and passive — Treatment : general and local— Necessity of proper regimen — Varies 
with the case — Different remedies which have been used — Local applications — Dia- 
phoretics — Sulphurous waters — Hygienic course. 

The treatment of both pericarditis and endocarditis, in their acute 
forms, will consist at first in free and frequent blood-letting, both 
general and local. M. Bouillaud, in the case of an adult in the 
vigour of life seized with pericarditis, orders, on an average, from 
three to four venesections, each to the amount of twelve or sixteen 
ounces, within the three or four first days ; together with the simul- 

* They who cannot consult the Traite Clinique du Cceur, t$-c, par J. Bouil- 
laud, Pofesseur de Clinique, &c, will find a very good digest of the work in an 
article taken from the British and Foreign Medical Review, and inserted in my 
Eclectic Journal of Medicine, for April and June, 1837. 

55* 



646 ACUTE RHEUMATISM. 

taneous application of twenty or thirty (French of course) leeches, 
or cupping to the extent of eight or twelve ounces during the same 
period. In feebler subjects, or where the intensity of the disease is 
not so distinctly marked, local blood-letting, by means of cups over 
the left side of the chest, or of leeches under the mamma of that side, 
must suffice ; to be followed by purging and counter-irritation 
by means of blisters, tartar emetic or croton oil to the chest. 
Tartar emetic internally, and colchicum in the manner already 
advised in acute articular rheumatism, should be used if the disease 
has not been arrested by bleeding. 

The treatment of acute endocarditis is essentially the same as 
that of pericarditis; or if there be a difference, it is only in the still 
earlier recourse to copious and repeated depletions, in order to pre- 
vent the coagulation of the blood, the deposition of false membranes 
within the heart and permanent derangement of its mechanism. 
Even when it supervenes on rheumatism in other parts, for which 
active remedies had been freely used, we ought not to be deterred 
from recourse to the means already indicated for its cure. In a 
case of endo-pericarditis, which succeeded to acute and violent 
rheumatism of the bowels, and for which I had bled both generally 
and locally, I had recourse notwithstanding to the lancet and to 
cups over the chest. The result was a complete convalescence and 
restoration to perfect health — rendered the speedier by the exhibi- 
tion of the sulphate of quinine after the depletions.^ 

In thus bearing testimony in favour of active depletion in endo- 
carditis and pericarditis, I ought to add, that the practice to the 
extent recommended and pursued by M. Bouillaud is only called 
for in those cases in which temperament, prior robustness of frame, 
and sanguineous plethora, with violent rheumatic seizure, conspire 
i to give these diseases great intensity at an early date. Subjects of 
a more mixed habit of body and constitution, and in whom the 
acute stage has passed into the sub-acute, or thence into the chronic, 
are better treated by moderate blood -lettings, to the avoidance of 
sudden or full impressions on the circulation ; and in these cases 
free and repeated local bleeding should be regarded and employed 
as a measure of at least equal importance. Dr. Williams recom- 
mends that calomel and opium should be given until the gums show 
their effects ; and he adds, that this combination seems to be most 
valuable twice or thrice in the day, as prescribed by Dr. Chambers. 
One ought to be very sure of the diagnosis before causing ptyalism, 
which aggravates common palpitation and other disorders of the heart. 
As the disease becomes more chronic, Dr. Williams directs two or 
three grains daily of the hydriodate of potash, with a view to pro- 
mote the absorption of the effused lymph. Of this remedy I should, 
from my own experience, augur favourably ; and particularly in 
synovitis, or where the synovial rather than the fibrous membrane 
has been the seat of inflammation. The hydriodate, but in doses 
often grains increased to thirty, three timesa day isused regularly by 
Dr. Graves towards the latter period of acute articular rheumatism. 
The relative infrequency of true muscular rheumatism of the 



PLEURODYNIA AND DIAPHRAGMITIS. 647 

heart renders it less necessary to enlarge on the symptoms and 
treatment of this affection when it is present ; the more especially 
I as the latter is conducted on the same principles which govern us 
I in articular rheumatism complicated with inflammation of the mem- 
| branes of the heart. 

! The other parts of the muscular system which are represented to be occasion- 
i ally the seat of rheumatism, are the diaphragm, and of that part belonging to 

animal life, the occipito-frontalis, the temporal, masseter, sterno-cleido-mastoidean, 
1 the superficial and deep-seated muscles of the thorax and the lumbar ones. In all 

these cases, however, I am inclined to believe that the tissue really affected is 
| the aponeurotic and tendinous expansions and interlacements, with occasionally 
! the subjacent and contiguous cellular tissue. This opinion would seem to be the 

more probable from the facts of all the muscles above mentioned being largely 
j supplied with fibrous tissue, — aponeuroses and tendons, and of the absence 
I of organic changes in the proper muscular tissue. Where, as in the case of 

abscesses of the masseter muscle, there is really an inflammation under the fasciae 

in the substance of the muscle itself, the sensations of the sufferer and the other 
j accompanying phenomena are far from being identical with those experienced 
! and noted in rheumatism of this part, and in which, among other peculiarities, the 
! patient sometimes labours under a sort of trismus. We are led also to the same 

inference by noting the severity of rheumatism when seated in the pericranium, 

a fibrous expansion in the disease of which no muscular tissue can be supposed to 

play a part. 

Rheumatic pains may attack all the regions of the spinal column, — the cervi- 
cal, dorsal, or lumbar vertebrae, — either in their articulations or in the muscles 
which unite them; or rather, as I believe, in the fasciae which extend from the 
j articulations over the muscles. M. Andral thinks that the true anatomical seat 
in that variety called lumbago, is in the investing membranes of the spinal mar- 
row. If possible, a still more painful variety is in the sacro-iliac articulations, and 
it may be in the investments of the sacral nerves at the same time. Of the tho- 
racic muscles, the pectoralis major and minor, which have, we know, a full share 
of tendino-aponeurotic structure, are occasionally affected with rheumatism. In 
the female this may sometimes simulate, or at least be confounded with a disease 
of the mamma. Rheumatism of the deeper seated or the intercostal muscles is 
designated by the term pleurodynia, which is liable to be mistaken for pleurisy, 
unless attention be paid to the fact, that, although in both diseases there is a 
catch, owing to severe stitch, in breathing, yet that the pain in the former is 
greatly augmented by pressure and movement of the body, whilst at the same 
time there is little or no fever. Pleurodynia has been mistaken for disease of the 
liver, of the kidneys, and of the intestines. But a mistake, of still more probable oc- 
currence, is the confounding of lumbago with chronic inflammation of the kidney, in 
which latter both pressure and, in degree, motion, aggravate the pain; but the rising 
up and sitting down, which are so difficult for a person affected with lumbago, will 
aid us to form a diagnosis of this latter disease. It is distinguished from overloaded 
colon, which is sometimes attended with pain in the back as well as in the hip, 
but which is detected by the unequal resistance on feeling the abdomen, and 
by an examination of the stools. 

Of all rheumatic inflammations of muscular structures, that of the diaphragm 
is by far the most distressing and painful in its symptoms and dangerous in its 
results. In such a case respiration is laborious, and accompanied with singultus 
and a sardonic grin, or convulsive distortion of the angles of the mouth ; there is 
acute pain and a cord-like constriction of the lower part of the thorax extending 
to the back and loins, increased and descending lower during inspiration, di- 
minished and ascending higher during expiration. The breathing is short, fre- 
quent, anxious, small, and performed entirely by the intercostal muscles — the ab- 
domen being nearly motionless. In'addition to these symptoms, the deglutition is 
frequently painful and difficult, and the patient sighs and exhibits a most anxious 
expression. Delirium is also a common adjunct to the other morbid peculiarities. 
The pulse is always frequent — at first strong and hard, afterwards small, more 



648 



ACUTE RHEUMATISM. 



quick and wiry. For full details on inflammation and other lesions of the dia- ? 
phragm I refer to Copland's Medical Dictionary. 

The treatment ought to be active in proportion to the alarming intensity of the 
malady ; and hence, in primary diaphragmitis, venesection, so as nearly to pro- 
duce syncope, the patient being in an erect or at least sitting up posture, will be t 
the first measure resorted to, after which cupping on the loins and back, leeches j 
under the sternum, purgatives, &c, are to be used. In acute rheumatism of the ■ 
diaphragm the same remedy to nearly the same extent should be used : but if it 
be of a more chronic character, or succeed to gout, then will cups to the loins, and 1 
leeches under the sternum be a suitable substitute for venesection ; they should l 
be followed by the use of active mercurial cathartics, colchicum, derivatives ap- i 
plied to the joints, and large doses of soda or potash with magnesia, ammonia, or 
camphor. 

The practitioner ought not to be deceived by the presence of singultus and the 
great depression of the powers of life so frequently attendant on diaphragmitis; 
so as to forego the use of the lancet, cups, and leeches in favour of autispasmodics 
and stimulants. Nor should he be induced, by the state of the stomach, and of the 
matters discharged from it, to exhibit emetics. After the first bleeding the author 
of the Dictionary cited above recommends recourse to large doses of calomel and 
opium in the true inflammation of the diaphragm, such as from ten to twenty 
grains of the former, and from one to three of the latter, either with or without 
from one to three grains of camphor, and repeated at intervals of six or seven 
hours. If inflammation of the adjoining viscera be associated with the disease, 
and the pleura and pericardium implicated, calomel, antimonials, and diuretics, 
ought to be used. 

Sciatica, commonly spoken of after lumbago, as a variety of 
rheumatism, is, in fact, an inflammation of the cellulo-fibrous en- 
velope, or neurilema of the sciatic nerve, and belongs to the class of 
neuralgic affections. As such it has already engaged our attention. 

The regimen, using the word in its large and appropriate sense, 
in acute rheumatism, ought to be exceedingly simple. Exquisitely 
and painfully sensible as the patient often is to cold air, and even 
to the momentary perflation caused by a sudden motion given 
to the bed-clothes or curtains, he ought to be protected against 
any action of this kind, whether by under currents affecting his 
feet when he is able to set up, or by drafts in the opening of doors, or 
through the crevices of these and of windows when he is confined 
to his bed. In an especial manner, also, is it the duty of the nurse, 
or other attendant in the sick room, to preserve a uniform tempera- 
ture, not less than 60 nor above 70 degrees of Fahrenheit, and to 
watch that the patient is not exposed during sleep by any deficiency 
of covering from the bed-clothes. 

The diet will consist for a while exclusively of simple drinks ; 
water alone, or an infusion of rice or barley of such temperature as 
may be most grateful to the patient, and weak tea — common, or that of 
the simpler herbs. One proof of the state of excessive hasmatosis 
and the hypersthenia of the system generally, which precede, and 
for a time exist after the coming on of acute rheumatism, is found 
in the toleration of extreme abstinence, not merely in the sense un- 
derstood by the physician, but in that, also, admitted by the patient, 
and evinced in his want of appetite and prolonged thirst, and 
call for drink alone. I have had a case of acute rheumatism 
under charge, in which large and frequent sanguineous depletions 
had been practised, together with the administration of the more 



CHRONIC RHEUMATISM. 



649 



j active remedies already indicated, and in which the patient for 
j three weeks ate but a few mouthfuls of bread and rice, and drank 
j little else than cold water. He had an aversion to and took little of 
I the drinks which I recommended, and which are appropriate for an 
j inflammatory febrile disease. But with a reduction of the pulse in 
j its frequency and hardness and a removal entirely of the local inflarn- 
, mation, together with a return of the skin and tongue to nearly their 
j natural state, came appetite and its allowably moderate gratifica- 
! tion. The quinine, I may mention here parenthetically, was given 
j at this stage with good effect in accelerating convalescence, which 
j was, ere long, complete. 

, I shall conclude this lecture with a few brief and summary re- 
| marks on chronic rheumatism. The term chronic should imply 
I simple duration without regard to the degree of structural change, 
or of functional disturbance. In pathology, duration is, however, 
j evidence in general of the relatively diminished intensity and vio- 
j lence of a disease ; since, we know that life is incompatible with its 
! unabated continuance; and hence, when we speak of a chronic affec- 
tion we connect with it the ideas both of a period of some duration 
from the date of its onset and of an abatement of the characteristic 
symptoms : but beyond this inferences cannot legitimately be car- 
ried. We have no authority from the premises for saying or sup- 
posing that acute and chronic are contrasted, as inflammation and 
I its absence, sthenia and asthenia, organic changes and their cessa- 
tion, would be. If there was inflammation in the acute stage of the 
disease there may be inflammation still in the chronic ; if fever in 
the former, this perturbation may be present also in the latter : the 
difference is in degree but not in kind. Divested, then, of hypothesis, 
and studied in reference to the facts of the case, chronic rheumatism 
is found to be manifested by similar symptoms, because it depends on 
lesions of the same tissues and order of parts, and on the same func- 
I tional disturbances with those of acute rheumatism. In both 
( stages, for so we ought to express it, rather than to say in both 
diseases, the pain may be either fixed in a part, or wandering 
to other parts ; in both, the heart, the alimentary canal, the kidneys, 
bladder, &c, may be the suffering organ. So long as there is de- 
cided inflammation, we might say progressive organic excite- 
ment in the joints, tending to the formation of new products, or to the 
thickening of tissues, there will be associated with it a quickened 
pulse, some increase of heat of the skin, a furred or loaded tongue, 
1 and imperfect cutaneous and renal secretions. Reference being 
| had to the symptoms in such a case, the disease might be called 
I active, as akin to, but less in degree than, acute : but, if we take 
| duration as the measure of our terminology, the disease must 
I still be qualified by the epithet chronic, since it may last in this 
| state for months. 

Chronic rheumatism may be articular or simply fascial. In the 
' first the organic changes are the same as those already noted in 
acute rheumatism. In the second the pains are felt more in the 
length of the limb ; in the muscles, as we are commonly told, but, in 



650 



CHRONIC RHEUMATISM. 



fact, in their fascia?, and at times, we may suppose, in the periosteum 
of the long bones. When the inflammation has lasted for a length 
of time the articular swelhng is increased ; the ligaments, the cap- 
sules, and the cellular tissue even, are sometimes blended into a 
mass which soon assumes a homogeneous and lardaceous aspect, 
and in which all traces of organization are lost. In some cases 
the synovial membrane is inflamed, the cartilages are exposed and 
partially destroyed, the ends of the bones softened and carious, and 
there seems to be no other resource for the unhappy patient than 
amputation. The limbs adjoining the swelled and rheumatic joints 
occasionally become emaciated and atrophied ; and if, for ex- 
ample, the elbow or the knee be the seat of the disease, the fore-arm 
is flexed on the arm, or the leg upon the thigh, and the flexor mus- 
cles acquire a habit of contraction, often most painful and at times 
incurable. White swelling is one of the effects of chronic rheu- 
matism. I have seen the hip-joint attacked with rheumatism, at first 
acute, then active, and finally assuming a chronic character, which 
ended in a partial dislocation and anchylosis; with some retraction 
of the thigh and stiffness of the muscles. The disease had lasted for 
several weeks before I was called to see it; and during all this time no 
active remedies had been used. Even after this, blood-letting and 
cupping gave great relief ; and, more than all the other remedies, 
of active purging, antimonials, &c, arrested the disorganizing 
process of inflammation. The patient was a little girl about seven 
years old. 

If you are called to treat such cases as this you will not allow 
yourselves to be deterred by the possible misconception of its na- 
ture by another physician or, what is more likely, the prior neglect 
and foolish quackery of the parents or friends for a long period 
previously, from adopting at once those measures to which the 
same symptoms at the beginning of the disease would have 
urged you. 

In giving advice in chronic rheumatism, it is proper to apprise 
the patient, that, although an occasional prescription may palliate 
unpleasant symptoms and procure for him a period of ease, yet he 
must not hope for entire restoration to health without persevering 
for a length of time in the medicinal and dietetic course marked 
out for him. It is necessary, also, to fix his attention on the func- 
tions, the proper performance of which constitutes the indispensable 
condition for his recovery. These are the digestive and perspira- 
tory : the organs, the gastro-intestinal mucous and the skin. The 
other important organs, the kidneys, will discharge their functions 
if the two first conditions have been carried out. But in chronic 
disorders, in which the skin, alimentary canal, and kidneys have 
been long implicated, we cannot hope for health until the morbid 
habits which they have contracted are broken ; and which require 
for their severance a deeper impression than is produced by the 
temporary disturbance and alteration of medicines, — short always 
of the destructive ones of mercury and arsenic. We must set 
about, therefore, a restoration of healthy habit through the channel 



DIVISIONS — TRE ATME NT. 



651 



of the organs of assimilation and nutrition, and by means of regimen 

in the large and philosophical sense ; that is, of suitable diet, exer- 
j cise, occupation, periods of sleeping and waking, and the adjuncts 
I of bathing and friction, and shampooing or massage of the skin. 
| These are the principal ; medicines and medical compositions the 
I secondary and auxiliary, but not on this account unimportant or 
; always dispensable. The subjects of chronic rheumatism may be 
I classed in two divisions : The first or active exhibits, in addition to 
I pain and tumefaction of a joint, febrile excitement ; a quickened and 

sometimes a rather tense, but small pulse ; a dry and somewhat hot 
I skin, but which readily perspires and as readily cools afterwards; 

a foul and furred tongue ; irregular state of the bowels ; urine often 
I high coloured and with a cloudy sediment. The sleep is disturbed by 
I dreams; the appetite is unequal, often wanting ; the disposition moody 

and fretful. The second or passive division shows proofs of torpor, 
, — 1, of the skin, which is cold ; 2, of the bowels, which are costive ; 

3, of the kidney, the secretion from which, though often copious as 
I regards the mere amount of fluid, is deficient in urea and saline 

proportions. The appetite is generally good, sometimes voracious; 

the tongue is moist — it may be large and whitish on its surface : the 
! frame of mind is rather apathetic than merely depressed. Sleep is 

obtained and enjoyed when it is not interrupted by pain. This 
I latter is seldom confined to a joint ; but wanders especially over the 

fascias of the muscles of the trunk and limbs and those of the head 

and face. 

In cases of the first division or analogous ones, the treatment will 
be similar to that adopted in acute rheumatism, with perhaps a 
less reliance on blood-letting, though still not to the exclusion of 
venesection from the arm. if the collection of symptoms seems to call 
for this remedy. If there is persistent fever, and with it symptoms of 
chronic pericarditis, or endo-pericarditis associated with or im- 
mediately preceding the disease of the joints, blood-letting is pro- 
per, but with more reserve as to the quantity and repetition than in the 
acute stage of these sero-fibrous inflammations. The extent to 
which you will carry purging will be influenced by the state of the 
stomach, — thirst and epigastric heat forbidding ; but in general this 
measure is required both on account of its directly ameliorating effects, 
and as a preparation for the use of remedies of another class called, 
we may suppose for want of a better name, alteratives. Purga- 
tives composed of calomel with some of the vegetable resins or 
extracts, such as jalap, colocynth, aloes, &c, will be required at 
| first; and afterwards the blue mass given in the evening, and 
, infusion of senna with some carminative in the morning. These 
measures, aided by a reduced regimen, short, however, of that 
j entire abstinence so useful in acute rheumatism, will of themselves 
I abate, if they do not remove, the local pain and constitutional dis- 
turbance ; and, at any rate, they will singularly facilitate the bene- 
ficial operation of opium, in the form of Dover's powder repeated 
at regular intervals during the twenty-four hours, and by warm 
drinks, until free sweating is produced. During the administration 



652 



CHRONIC RHEUMATISM. 



of diaphoretics, or of opium alone, which so often acts as a diapho- 
retic, the patient should be kept in bed in a room of an even and 
moderately elevated temperature. The vinous tincture of colchi- 
cum, alone or in conjunction with laudanum, but in smaller 
doses and at larger intervals than when it is taken for acute 
rheumatism, is a useful remedy at this time, and particularly if 
there be any remains of febrile action. In this form of dis- 
ease, as well as in rheumatic gout, for which the remedy has been 
more particularly recommended, the colchicum powdered minutely 
with loaf sugar, would be of service. Mr. Wigan advices it in a 
dose of eight grains every hour, in a medium most acceptable to 
the patient, until what he calls the point of saturation is obtained ; 
which is generally after eight or ten doses have been taken. 

If the skin is cold, and there is much exhaustion by prior disease, 
or profuse but exhausting sweats, quinine will be administered 
without delay in a dose of five grains early in the morning ; its use 
at this time having been preceded by that of five or eight grains of 
the blue mass, or half a drachm of the tincture of colchicum seeds 
in the evening before. In the efficacy of this practice experience 
has given me considerable confidence. It is that to which you 
should have recourse at once in the torpid cases of the second division, 
— contenting yourselves with having given an active aloetic purge, 
such as of five to eight grains of aloes and a drachm of sulphate 
of potash, on the day before you begin the quinine, and omitting the 
blue pill and the colchicum. In the mixed varieties of chronic 
rheumatism, in which the digestive functions are impaired, the blue 
mass given in combination, as with hyosciamus or stramonium, 
in such doses as to insure an obvious effect on the intestinal secre- 
tions, and consentaneously on the nervous system, seems to me to be 
preferable to the calomel and opium so generally and often so 
lavishly and empirically prescribed, with little reference to other 
immediate or remote effects on the systems just specified. 

Among the numerous, one might say innumerable, remedies for chronic rheu- 
matism, favourable notice has been made by Armstrong of the mountain flax 
(Linum catharticum) ; and by Brera, of the Ballotta lanata in decoction, pro- 
cured by boiling half an ounce of the plant in an unglazed vessel with as much 
water as when strained shall amount to eight ounces, which quantity is to be 
taken at four doses in the twenty-four hours. The alcoholic extract of aconite, 
on the authority of Drs. Lombard, Sigmond, and others, in a dose of a quarter of 
a grain every two hours gradually increased to six or eight grains in the same 
period ; and the decoction of the cimicifuga or black snake root among ourselves, 
have been used with benefit. Of the remedies whose action is more particularly 
directed to the tissues by modifying their nutrition, it will suffice to mention the 
chief ones ; viz., arsenic in the form of Fowler's solution, two drops twice or 
thrice a day ; corrosive sublimate, a twenty-fourth part of a grain ; and iodine and 
its salts. The effects of the corrosive sublimate and of the iodine are augmented 
by the simultaneous use of the infusion or the compound syrup of sarsaparilla. 
My own experience would make me partial to a solution of the hydriodate of 
potash, or of this salt and of the iodine itself — Lugol's solution, with the syrup 
of sarsaparilla. Dr. Otto relates his success, in cases of obstinate chronic rheu- 
matism and of sciatica, with the carburet of sulphur, in the form of a tincture, — 
two drachms of the carburet in half an ounce of rectified spirits of wine, for in- 
ternal use ; and a liniment, composed of two drachms of the carburet in half an 



DIAPHORETIC REMEDIES. 



653 



ounce of olive oil, for external use. Dr. Graves, with a view of meeting the 
double indication to act on the alimentary canal and the skin, and to preserve the 
strength of the patient, ha& prescribed the following formula, similar in its com- 
jj position to a well known popular remedy in Great Britain, called the Chelsea 
| pensioner: — R. Powdered bark, Ji; Powdered guaiacum, Ji; Cream of tar- 
I tar, ^i; Flower of sulphur, %ss; Powdered ginger, to be made into an 
! electuary with common syrup. The ordinary dose is a teaspoonful three times a 
! day ; but in this respect the quantity must be varied in different subjects, so as to 
i keep up a mild yet steady action in the bowels, and to procure a fa]l alvine dis- 
j charge at least once a day. The mezereon, guaiacum, volatile alkali, separately 
| and combined, have been proved in chronic rheumatism. Dr. Chapman retains 
his partiality, long ago expressed, for savin in this disease. It must be given in 
full gradually increased doses until an itching and heat are felt on the skin. 

But neither these various remedies nor others that might be cited, 
if a catalogue rather than a methodical distribution were the ob- 
I ject, should cause us to forget the alleviating, if not positively cura- 
tive, powers of opium and its different preparations. Of more 
uniform strength, and convenient exhibition than any other medi- 
! cine of the vegetable tribe, opium has the additional advantage of 
I producing effects which, whether propitious or otherwise, can soon 
be appreciated, and serve as a guide for its subseo A uent administra- 
tion. In rheumatism of a decidedly chronic character, /and more 
especially in that variety in which the muscular aponeuroses and 
other fibrous membranes are affected, and in which the pains are 
erratic, yet severe and harassing, the nervous system has the ascen- 
j dency over the vascular. In such a state will opium given in full 
doses display its benign effects. Among these, and a no small evi- 
dence at any time of its adaptation to the case and stage of dis- 
ease, is diaphoresis, or at least a softness and warm moisture of the 
skin. It has seemed to me that this effect more frequently and 
readily ensued on the administration of the salts of morphia than of 
solid opium or laudanum. I have succeeded in giving entire relief 
to a person who had been afflicted for some days with violent scia- 
tica, by directing a grain of the acetate of morphia, in solution, of 
which a fourth part every hour was taken until the wmole was used. 
Venesection to the extent of a pound had been previously practised 
by my direction. 

It is in the torpid and atonic states of the system, when it is suffer- 
ing from chronic rheumatism, that the sweating method has been 
serviceable. In order to give full effect to this part of the treatment, 
a direct impression should be made on the skin by prolonged im- 
! mersion in a warm bath of about 96 to 98 degrees ; the same 
i nearly with that of the deservedly celebrated Warm Springs in 
I Virginia ; or, what is preferable, by the application of simple watery 
vapour, for a period of from twenty to thirty minutes. The vapour 
of alcohol, in the manner recommended and successfully prac- 
tised by Dr. Jennings of Baltimore, and that of sulphur, have been 
productive of the best results in chronic rheumatism ; more particu- 
larly in cases in which there was stiffening of the joints, with swel- 
ling of the bursa? and dropsical effusions. The temperature of the 
vapour from water need not be less than 95° F., nor, advantage- 

56 



654 



CHRONIC RHEUMATISM. 



ously, more than 120.° In active rheumatism, or in those cases of 
chronic in which there is still some fever and gastric irritation, the 
vapour ought to be at the minimum temperature; whereas, in the j 
more protracted cases, with cold skin and rigid joints it may be used 
at the maximum. For numerous additional details respecting the 
method of evolving and of applying vapour, and of the auxiliary 
processes of friction, as also of the application and virtues of douch- 
ing with hot water and vapour, I must refer you to my work on 
Baths and Mineral Waters, in which these and kindred subjects arc 
fully discussed. The douche or spout bath, is one of our best, 
perhaps the very best discutient, to use an old fashioned term, but 
one as expressive and therapeutical as any of more recent origin. j 

Simple hot air, with certain substances volatilized in it, as benzoin, amber, 
juniper leaves, has been used with alleged good effect. The testimony in favour 
of sulphur baths is still stronger. Of late years camphor, vapourised by being 
thrown on a plate of hot iron, has been extolled by M. Delormel. Instances are re- 
corded of the heat in some of these dry vapour baths having been raised to 70° of the 
centigrade thermometer, or 158 of Fahrenheit, without any inconvenience being 
experienced by the patients. In these cases, either the head is entirely external to 
the bath, or a communication is established between the mouth and the common air. 
This precaution, generally proper, is indispensable with subjects of a plethoric habit, 
who are disposed to a determination of blood to the head or to haemoptysis. 

When the pain and swelling of a joint persist after suitable local depletion, succes- 
sive blisters, the vesicatoires volans of French writers have a beneficial effect. The 
following is the manner of employingthem to the best advantage. A plaster of can- 
tharides of moderate size is to be applied on the affected joint, and after twenty-four 
hours it is to be removed, and the blistered surface dressed with cerate, having merely 
opened the raised vesicle without detaching any of the epidermis. So soon as this 
heals, a second blister is to be put on another part of the joint, and to be followed by the 
dressing, as before ; and so on until the desired relief is obtained, or a cure accom- 
plished. The patient often expresses himself as benefited after each blister. 

Various embrocations and stimulating liniments have been used for the purpose 
both of abating pain in a joint, and of removing the ind uration and thickening of tissues 
by which it is enlarged. An enumeration of these is hardly to be expected, nor is it 
necessary on this occasion. Oil of turpentine and water of ammonia are the basis of 
most of them, to which some empirics add tincture of cantharides, croton oil, tartar 
emetic, &c, so as to make a liniment which at times gives decided relief by the 
counter-irritation of the skin to which it is applied ; but which, heedlessly andignor- 
antly used, has caused not only ulceration of the skin, but permanent deformity of 
the subjacent tissues. Mr. Laycock, of York, Eng., has given cases to show the 
good effectsof the tincture of colchicum and champhor rubbed on the pained parts. 

M. Gondret, in a work on Derivation as a means of relief and cure of 
Plethora, Inflammation, Hemorrhage, &c, takes great pains, first to 
describe all the means which he uses for the purpose of counter- 
irritation, and then their different degrees of strength and adaptation 
to the several stages of the disease. — (British and Foreign Medical 
Review, 1839.) 

One of the favourite means which M. Gondret employed for the purpose of 
producing counter-irritation, and thus relieving rheumatism, both acute and 
chronic, is what he terms ' pommade ammoniac ale the preparation of which is 
thus described : Take of hog's lard seven drachms, of oil of sweet almonds one 
drachm and a half, and of liquid ammonia (of twenty-five degrees) from five to 
six drachms. Melt the hog's lard, mix with it the oil, and pour them into a 
wide-mouthed bottle with a ground-glass stopper ; then add the ammonia, close 
the bottle, mix the contents together by shaking, and keep the mixture in a cool 
place. A report of a committee of the French Royal Academy of Science is 



HYGIENE— MINERAL WATERS. 



655 



j strongly in favour of this remedy, which is represented to be more prompt in its 
j action than cantharides, exempt from the distress occasioned by the absorption of 
j this medicine, and capable of much more varied effects. If the skin is to be ex- 
cited, perspiration re-established, and some sub-cutaneous engorgement to be dis- 
sipated, light and hasty frictions accomplish these objects. If a rubefacient effect 
'! is sought, its application for one or two minutes spread thickly on linen answers 
j the purpose. In case vesication is required, a similar application for five or ten 
1 minutes produces the effect. On the other hand, should absolute cauterization be 
| desired without alarming the patient, or shocking the prejudices of certain medical 
j men against the cautery, a somewhat longer application attains this end. 
! Not only in chronic articular rheumatism, but in the fascial and neuralgic 
I varieties, this pomade will be found serviceable, if rubbed along the course of the 
! pain or, as in sciatica, of the nerve itself. 

Among the local means of relief we may enumerate rollers applied with some 
| degree of tightness round the affected limb and joint. More benefit is ex- 
pected from this process, if at each time of the renewed application of the roller, 
once or twice a day, friction be assiduously practised ; and, in addition, some lini- 
ment or ointment rubbed on the part. Dr. Graves mentions the entire relief pro- 
cured by this plan, in a case of most obstinate chronic articular rheumatism, which 
jj had been intractable to a great variety of remedies, among others of mercury to 
the extent of salivation. The medication which he directed in the case was to 
rub mercurial ointment gently over the affected parts, assisting its action by the 
use of rollers in the way just specified. The mouth was affected by this inunc- 
j tion. In a similar state of disease I have used the ointment of hydriodate of pot- 
ash with benefit. The commentary offered by JJr. Graves on the question, 
whether good can result from the local application of mercury, unless it affect the 
general system, is applicable to the use of both the ointments here mentioned. 
He argues that there is no necessary connexion between the local and general 
effects, in regard to the topical use of mercury ; and that although ptyalism fol- 
lows in cases, yet in others unequivocal benefit is obtained without this result. 

Acupuncturation, an old remedial means revived some years ago, 
has afforded, unquestionably, with all due deductions for the cre- 
dulity of physicians, and the imagination of patients, relief from 
harassing and severe pain in this form of rheumatism, as it has 
also done in certain varieties of neuralgia. 

I must forego for the present addressing you on the subject of the details of a 
full hygienic course, requisite to be pursued by the rheumatic invalid, as well to 
complete his cure as to prevent a return of the disease. This would embrace a 
consideration of the use of mineral waters, particularly those of the sulphurous 
kind ; sea-bathing; change of climate ; and travel, &c. ; and an observance of the 
rules of temperance in the exercise of both his bodily and mental functions. The 
resources from which the patient must mainly draw, are furnished by regimen 
more than by medicine. On the regulation of his habits, his command over his 
appetites, his prudence and perseverance, will his entire restoration to health 
chiefly depend. A point of the first, if not paramount importance, is to restore 
the digestive functions to a healthy state, — a result to be procured, not so much 
by daily purging, or by the alternation of purgatives and tonics, though these 
are at times admissible, as by wholesome food — moderate in quantity, simple, 
yet tasteful in quality — walking in the open air, or riding on horseback, — 
and by the lighter sports, or gymnastic exercises, which call into action all the 
limbs, and the muscular system generally, without strainer stretch. 

The pleasantest natural warm bath, of a temperature the best adapted to 
most cases of advanced chronic rheumatism, is that of the Warm Springs; and 
hot bath, at the Hot Springs, Virginia. The saline sulphurous water, which 
has deservedly acquired the greatest vogue, is the White Sulphur Spring, 
thirty-five miles distant from the Hot. Akin in virtue to those of the White 
Sulphur, are the waters of the Salt and Grey Sulphur. Of a temperature 
midway between that of common water and of the Warm Spring, is the natural 
bath of the Sweet Springs, which, on this account, is well adapted to the 



656 



CHRONIC RHEUMATISM. 



cases of rheumatism in which the Hot and even the Warm Springs are found to 
be too exciting-. The invalid whose stiffened limbs have acquired freedom of 
motion by the spout bath or douche at the Hot Springs, and general bathing at 
the Warm, might advantageously complete his course, and prepare himself for j 
encountering the common fluctuations of atmosphere, by daily bathing for a while 
at the Sweet Springs. 

The high and deserved reputation so long enjoyed by natural sulphurous water, 
for the cure of chronic rheumatism and many other chronic maladies, has not 
prompted physicians to prescribe artificial sulphurous and saline waters to the 
extent, and witfi the frequency which, from my own experience, would lam sure 
be justifiable and proper. I have often derived the best effect from the sulphuret 
and sulphat of potash, with sulphate of magnesia largely diluted in water, and 
drank once or twice a day for some weeks. If there be hepatic complications, or 
enduring disorder in the digestive canal, indicated by a loaded and furred tongue, 
and other concomitant symptoms, especially of scanty and perverted renal secre- 
tion, I prescribe three to five grains of the blue mass in the evening, and the saline 
and sulphurous water in the morning before breakfast and, if necessary, i 
at noon, or thereabouts. The proportions of the latter are as follows : Sulphuret 
potass. 5* j sulphat potass. ^ ij ; sulphat magnes., %ss; aqua fluvial, jfoij. 
After shaking up this imperfect solution, the dose is a wine-glassful, to be taken 
still further dissolved in a tumbler-full of water. The proportion of the two sul- 
phates will be, of course, increased when it is desired to act on the bowels. Care 
should be taken to keep the bottle which contains this mineral water closely 
stopped. The occasional use of the warm bath, and twice daily frictions of the 
whole cutaneous surface, will aid the good effects of the water. 

In common, and when there is no special tendency to an increase of the perspi- 
ratory function by the use of sulphur or diaphoretics, a substitute for sea bathing 
will be found in an immersion for a few minutes, sometimes less, in a cool bath of 
about sixty-five degrees, saturated with salt — or what will be more convenient and 
adapted to a greater variety of cases and complications, daily sponging the surface 
in the morning after rising with salt water, and then rubbing it well with a dry 
towel and a flesh brush. 

But whatever value we may attach to these and other parts of an alterative and 
prophylactic course of treatment, the essential ones are, after all, to be found in 
regimen — plain food taken at proper hours and after proper intervals; regular ex- 
ercise; and an avoidance of all the causes which enfeeble the nervous system, 
and thus predispose the erring individual to the morbid impression of atmospherical 
vicissitudes. Among these causes, and almost on a line with positive and debasing 
sensual indulgences, is prolonging the period of study or of business application 
fir into the night. A minute specification of the articles of food proper to be used 
by a rheumatic invalid, who is going about, and who is intent on preventing a 
return of his malady, need not be given here. In the selection, something will 
depend on his own personal experience of their relative digestibility ; something 
in the facility of procuring them. It may be laid down, however, as a general 
rule, that if he had been in the habit of free repletion he must eat less, no matter 
how simple may have been his fare ; and if, a more probable supposition, he have 
erred by using mixed and stimulating food, he must substitute unity and simplicity 
in its stead, remembering, however, that the meal of one day need not be representa- 
tive in every particular of that of the next. Each day should be marked by plain- 
ness of food used ; but there may be, as regards many days, variety with simplicity. 
If the milk regimen accord with his former custom, and be found to agree with his 
stomach, it ought to have the preference, with its proper adjuncts, good but never 
warm or fresh bread, well boiled vegetables, and ripe fruits in their season. Green 
and acid fruits are unfriendly to those afflicted witfi rheumatism. 

On the score of drink there is only one proper for both the rheumatic and 
the gouty invalids, who really desire to recover their health and entire usefulness ; and 
that is water. If its coldness offend the stomach, it is easy to amend this fault; if 
saline or earthy matters are in excess, boiling and a common filter will produce 
nearly all the requisite changes ; at any rate, so far as to preclude all excuse for 
adulterating the water by the admixtureof ardent spirits, or wine. Putting aside all 
special pleading, as to the temporary relief procured by distilled spirits and vinous 



CHRONIC LARYNGITIS. 657 

and malt liquors, the plain proposition is proved beyond all reasonable question, 
I that, for any thing like perfect recovery and subsequent exemption from the violent 
j attacks of acute, or the harassing and wearingdown ones of chronic rheumatism and 
ij gout, a simple regimen— one of the chief features of which will be abstinence from 
j ardent spirits or fermented liquors — is a sine qua non. In thus specifying the 

kind of drinks to be abstained from, it is not meant, however, to under-value the 
1 injury from persistence in gross alimentation, nor the great advantages from a 
! marked change of living in this respect. 



LECTURE XII. 

Chronic Laryngitis, its synonymes — Seat of the disease — Structural changes — Appli- 
cableness of the title — laryngeal phthisis. Large proportion of ulcerations in the 
epiglottis, larynx, and trachea in phthisical subjects — Symptoms : sensations, voice, 
j aphonia, cough, breathing — Different species of chronic laryngitis, — a knowledge of, 
! necessary for prognosis and treatment — Examination of the fauces and pharynx — 
To determine the state of the lungs : auscultation, percussion, and expectorated 
I matter — Duration of the disease — Causes: age, sex, prior disease, vocal strain, 
I atmospherical vicissitudes, habits — Treatment : rest of the vocal apparatus, anti- 
j| phlogistics, counter-irritants, narcotics, mercurials, iodine, sarsaparilla, balsam 
of copaiva, blue mass and syrup of sarsaparilla, sulphurous waters — Topical reme- 
4 dies : inhalation of simple and stimulating vapours, caustic to the parts, attention 
to anginose complication — Syphilitic chronic laryngitis : mercurials, sarsaparilla, 
iodine — Tracheotomy, when proper — Prevention of the disease — Clergymen,—- rules 
for their guidance — Uniform temperature of air — Jeffray's Respirator— Change of 
climate. 

The disease which is the subject of the present lecture has been 
j variously named. In addition to its technical designation of 
Chronic Laryngitis ; Laryngeal Phthisis ; Laryngitis with 
Secretion of Pus ; it has received the popular ones of Clergyman's 
Sore Throat : Throat Consumption, &c. 

Chronic Laryngitis may be the consequence of primary acute 
laryngitis and idiopathic ; or it will show itself after a very brief, 
and by no means violent stage of acute phlogosis of the organ, and 
be combined with and a symptom of chronic affections of other 
parts, particularly of pulmonary tubercles, and occasionally of 
secondary syphilis. The effects of chronic irritation on the larynx, 
! vary from a slight vascularity and thickening of the mucous mem- 
brane, to changes so extensive as completely to alter and destroy 
the natural appearance of the canal. The successive changes in 
the laryngeal mucous membrane may be redness ; thickening or 
diminished consistence; softening, partial or general; sometimes 
vegetations or excrescences of a considerable size. Pus may be 
met with on its surface. Participating in these alterations, the 
mucous follicles may become enlarged and thickened, and secrete 
more abundantly than common. Ulcerations are met with, which, 
1 according as they are above or below the vocal chords, will cause 
i impaired voice or complete aphonia : they have been chiefly met 
i with in the epiglottis, the aryteno-epiglottidean ligaments.; the vocal 
chords; and the base of the ventricles; and they may become so 
j extensive as to give rise to fistulas. The sub-mucous cellular 
| tissue may be thickened, and appear under the form of schirrous 
chords, or be distended with effused serum. In this tissue have 

56* 



658 



CHRONIC LARYNGITIS. 



been found purulent collections and tubercles in every stage of 
development. 

The muscles of the larynx are, at times, reduced in size ; softened, 
or even entirely removed : and again they are in a state of hyper- 
trophy. The disease being protracted, the cartilages become 
affected ; the epiglottis may be thickened, ulcerated, carious, even 
completely destroyed. The thyroid cartilage is less frequently 
changed ; the cricoid is sometimes hypertrophied and carious ; the 
arytenoid may be destroyed ; and, on the other hand, all the carti- 
lages may be ossified. In general, the ulceration begins in the 
mucous membrane, and extends to the cartilages. Serous cysts, 
and even calculous concretions have been found in the ventricles 
of the larynx. — (M. Andral, Cours de Pathologie Interne.) 

The propriety of the term laryngeal phthisis is supposed to rest 
on the occurrence of the symptoms of consumption and its fatal 
termination, in consequence of organic changes which take place 
in the larynx. That such cases have been met with is not denied ; 
but the number is very small. In a great majority of those persons 
who have sunk under disease whilst attacked with chronic laryn- 
gitis, there has been found to co-exist tubercles of the lungs. Some- 
times these last follow, but more frequently precede the laryngeal 
affection. The upper part of the respiratory apparatus is the chief 
sufferer from ulceration in phthisis. Of one hundred and two con- 
sumptive patients noted by Louis, the trachea was found to be 
ulcerated in thirty-one, the larynx in twenty-two, and the epiglottis 
in eighteen. In the whole of his researches up to the time of 
making this record, he met with only seven cases of ulceration of 
the bronchia. Hastings gives, it is true, a larger proportion ; the 
mucous membrane of this part having been, according to him, ulce- 
rated in all those (leather dressers of Worcester) who died of 
chronic bronchitis. Andral tells us (Clinique Medicale), that of 
the whole number of cases which have come under his observation, 
in three-fourths of them there~were ulcerations of the larynx. 

Even though chronic laryngitis without complication should 
seldom be productive of consumption, the designation phthisis laryn- 
gea will still be applicable to those cases of tubercular pulmonary 
consumption in which the disease is aggravated, the symptoms in a 
degree characterised, and its march accelerated by the laryngeal 
affection. 

The symptoms of chronic laryngitis are local and general. The 
local are derived from the feeling of the part, the voice, cough, 
expectoration, appearances, state of the respiration, and deglutition. 
The general symptoms are often slight, and are only manifested 
towards the last stage, or occasionally at the onset of the disease. 

The uneasy sensations are chiefly confined to the larynx, and in 
this are commonly in one spot only; as at the upper and lateral 
part, for example, of the thyroid cartilage. Sometimes there is a 
simple, pricking pain ; at other times no complaint is made 
whatever, even when the larynx is the seat of extensive ulcerations. 
There is usually a tickling which excites cough, — sometimes a 



APHONIA-COUGH. 



659 



feeling as if an extraneous substance were lodged in the larynx; 
and again of erosion, burning, and even lancinating pain. This 
pain is aggravated by coughing, speaking, and swallowing; espe- 
cially if the ulcerations are above the ventricles of the larynx, and 
also by inspiring cold air, and by pressure on the larynx. 

The voice is almost always altered in its tone, and this change is 
one of the earliest symptoms of the disease. At first it is merely 
weak; but more frequently hoarse ; and sometimes entirely extinct. 
The hoarseness is sometimes continued ; and at other times comes 
on only when the larynx is fatigued, or the patient is exposed to a 
temperature which differs much from that in which he habitually 
lives. If the individual suffer from severe hunger, the hoarseness 
is much increased, but disappears after a meal. Immediately 
before menstruation, as well as after venereal indulgences, the 
hoarseness becomes greater. Dividing the duration of the disease 
into three periods, it will be found that during the first the hoarse- 
ness is intermittent, during the second it becomes continued, and may 
so remain to the end, though more frequently complete aphonia 
supervenes during the second stage. 

Aphonia may be intermittent or continued. In the former case 
the voice is lost at night, while in the morning, or after a meal, it is 
merely hoarse. Continued aphonia is a bad symptom. Inequality 
of voice is a symptom which more frequently occurs in laryngeal 
phthisis than the patients themselves suspect. When the larynx is 
diseased the volume of the emitted sound is lessened ; and, in general, 
the emission of air is proportioned to the intensity of the voice. 
Hence discordant and unequal intonation is avoided. But the voice 
becomes discordant and squeaking in those who attempt to give it 
the full development which it possessed before. This has been 
observed in several singers and pleaders, and in clergymen who 
persist in the performance of their clerical duties when their voice 
has lost its accustomed pitch. 

The cough is a constant accompaniment of chronic laryngitis, 
which cannot always be said of disease of the lower parts of the 
respiratory apparatus. It is hoarse, and even croupal, when there 
is tumefaction of the mucous membrane ; and generally dry, or at 
most partially relieved by puriform mucus and sputa mixed with 
blood. Sometimes pure blood is expectorated : at other times false 
membrane is expelled once daily for some months, and a more 
than usually copious discharge has been followed by convalescence 
and restoration to health. Mixed with purulent or sanguinolent 
mucus, are occasionally seen the remains of carious cartilages of 
the larynx. In those affected with aphonia or stridulous hoarse- 
ness the cough is very peculiar: it has been called eructation by MM. 
Trousseau and Belloc — the latest and most careful describers of the 
disease. The frequency of the cough is not, however, a measure 
of the state of the larynx. Some persons on whom there has been 
found great lesion of this part have hardly coughed at all ; whilst 
others have been teazed with an incessant cough, in whom both 
the lungs and the larynx are sound. 



660 



CHRONIC LARYNGITIS. 



The breathing is not much affected in the milder forms and early 
stage of chronic laryngitis; that is, when there is no diminution of 
the common diameter of the glottis. After the second stage of the 
disease is reached, anhelation is marked and goes on increasing 
until death takes place. This anhelation may proceed from two 
causes ; muscular debility, the result of general weakness, or nar- 
rowness of the orifice of the larynx. In the latter case it takes the 
following course : at first the patient feels himself liable to what he 
calls fits of asthma, which most frequently come on at night ; at a 
later period the severity of the paroxysm is increased, and the op- 
pression is permanent. The patient cannot breathe on his bed, 
unless supported w 7 ith pillars, and then the inspiration is habitually 
sibilant, and the expiration loud and prolonged. Paroxysms of 
true orthopnea soon supervene, during which there is extreme 
anxiety and threatened suffocation ; and, generally, in fifteen or 
twenty days from this time the patient dies suffocated. 

When the ulcerations are situated at the superior orifice of 
the larynx, deglutition is impeded, giving rise to some uneasi- 
ness and cough ; but in cases in which the epiglottis is in part in- 
flamed or removed by ulceration, there is much dysphagia with a 
return through the nostrils of the drinks taken in by the mouth, and 
a fixed pain in the superior portion of or immediately above the 
thyroid cartilage. Still, as if to prevent positive conclusions re- 
specting the effects of evident organic lesions, we learn from Ma- 
gendie, that there have been cases in which, notwithstanding the 
complete destruction of the epiglottis, deglutition was performed 
without abnormal symptoms. 

In some cases of chronic laryngitis, pressure on the larynx by 
grasping it betw-een the finger and thumb produces a crepitation, 
which is alleged to be caused by caries of the cartilages, and by 
some it has been regarded as a pathognomonic sign of phthisis 
laryngea. But renewed experiments showed that this occurs when 
the organ is perfectly sound. 

It is important to be aware of the different symptoms in the dif- 
ferent species of chronic laryngitis or laryngeal phthisis. The pro- 
gress of syphilitic is not the same as that of simple laryngeal phthisis. 
The latter generally originates in the larynx and trachea ; whereas, 
the former usually spreads from the pharynx and nasal fossae. It is, 
we are told, of great practical importance to attend to this, because 
experience shows that the larynx is usually affected in the same 
manner with the throat. Thus, when an erythematous syphilitic 
affection is observed in the throat, the affection of the larynx will 
not be of an ulcerous nature ; and, on the contrary, when the bowels 
and velum palati and nasal fossae are deeply ulcerated, w r e may 
expect to find the larynx ulcerated or eroded. 

In every case of chronic laryngitis we should examine the fauces and pharynx, 
in order to see whether, and to what extent, their mucous membrane is affected. 
Frequently, there are disease of these parts and digestive disorder associated with 
that of the larynx, and although we may Dot be able to reach this latter by topical 
remedies, we can exert a salutary effect on it through applications to the fauces 



AUSCULTATION AND PERCUSSION. 



661 



I and pharynx. I have, after careful and repeated examination, detected in this 
way ulceration at the lower part of the space between the pillars of the palate ad- 
joining the upper part of the larynx ; on cauterising- which, the laryngeal affection 
I was greatly relieved. Elongation of the uvula is of itself a frequent exciting cause 
I of cough and of irritation of the glottis, and through this latter of the whole respi- 
] ratory apparatus. Its excision is often necessary for a cure, and at times the ope- 
. ration alone will be found sufficient for this end. An inspection of the epiglottis 
! is very desirable, since the larynx is seldom severely affected without this part par- 
1 ticipating in the disease. Sometimes by getting the patients to utter loud cries 
i during the inspection, the epiglottis, carried forward at each expirat ion, may become 
j visible. As yet, little benefit has been derived from the use of speculums invented 
with a view to our examining the larynx by their means. The trials made to as- 
I certain by the introduction of the finger the state of the epiglottis and upper part 
of the larynx, must be regarded as hazardous, although the practice has been 
recommended with some emphasis in cases of suspected cedematous laryngitis, in 
order to allow of our obtaining thereby a satisfactory diagnosis. 

Believing the title of laryngeal phthisis to be sufficiently compre- 
hensive, both to express consumption which may result from simple 
| chronic laryngitis, as well as that which has its origin in pulmonary 
tubercles, and to which the disease of the larynx furnishes some of 
the chief characteristic symptoms, I do not see the necessity of 
using the terms tubercular laryngeal phthisis. It is sufficient for us 
to be aware of the fact, that with organic lesions of the larynx of 
a chronic nature there is commonly complicated a tuberculous 
state of the lungs, which is, after a time, converted into true phthisis. 
In forming, therefore, our diagnosis and prognosis of diseases of the 
larynx, an examination of the state of the lungs can never be 
omitted. On this point, the advice of Dr. Stokes should be regu- 
larly and fully acted on. — [A Treatise on the Diagnosis and Treat- 
ment of Diseases of the Chest. Part I.) 

"The first step in the investigation will be to examine accurately into the his- 
tory of the case; and in particular to determine whether the laryngeal affection 
was primary or supervened on an already existing- state of the lung. We must 
examine what were the first symptoms, and whether they were referrible to the 
larynx or lung. We must inquire into the past and present state of the fauces, 
and also whether a syphilitic taint exists. Now, should it be found that the first 
symptoms were those of a laryngeal character, that the voice had been altered 
from the outset of the disease, or that a syphilitic taint did really exist, we have 
a good probability, not that the lungs at the time of examination are free, but 
that the first morbid action was exercised on the larynx. But if, on the other 
hand, we find that, previous to the occurrence of any hoarseness, or stridor, or 
dysphagia, there has been cough without the laryngeal character — particularly if 
it was at first dry, and afterwards followed by expectoration — if hectic has 
existed, although the expectoration continued mucous; if there have been hsemop- 
tysis, pain in the chest or shoulders; and, lastly, if the patient was emaciated pre- 
viously to the setting in of the laryngeal symptoms — we may be almost certain 
that tubercle exists, and that the case, so commonly called laryngeal, is in reality 
pulmonary phthisis ; and if it appears that the patient is of a strumous habit, or 
has already lost brothers or sisters by tubercle, we may form our diagnosis with 
a melancholy certainty, even though, at the time, we can detect no certain phy- 
sical sign of pulmonary tubercle." 

It follows, from these premises, that we must have recourse, in 
our diagnosis, to the stethoscope, the nature and abundance of the 
expectoration, and the rapidity of the consumption. But as Dr. 
Stokes has stated, in the work just quoted from, the sounds which 
would be conveyed to the ear through the stethoscope and consti- 



662 



CHRONIC LARYNGITIS. 



tute the phenomena of respiration, are greatly obscured or masked 
by the state of the larynx, when this part is the seat of the disease. 
Fortunately, percussion serves us here instead of auscultation and 
enables us to determine which lung, and of the diseased one which 
part is affected. " Under any circumstance," says Dr. Stokes, 44 the 
localized dulness points out that there is something more than 
laryngeal disease; and we know from experience that that something 
more is, in the great majority of cases, tuberculisation of the lung." 

Between laryngitis and tracheitis, either simply as such or asso- 
ciated with phthisis, it is difficult to distinguish. In the former we 
may expect dysphagia, and the voice to be more affected — in its being 
muffled, hoarse, or wanting — than in the latter. Among the termi- 
nations of laryngeal phthisis one of the most severe is swelling of 
the margins of the glottis. The primitive laryngeal angina, of 
which this is an accompaniment and a symptom, has been already 
described with requisite fulness. The consecutive is occasioned by- 
organic lesion of the larynx and its connexions, and may be either 
inflammatory or active, or non-inflammatory and passive. 

In duration, chronic laryngitis will vary from a few months to 
many years. For us to augur a favourable termination, the disease 
should have made but little progress. When it has advanced con- 
siderably, and the system is weakened by dyspnoea, cough, pro- 
longed abstinence or marasmus, there is little hope of saving the 
patient. But as there are on record accounts of several patients 
in whom the disease had made great progress, and who were never- 
theless cured, it shows the propriety, and indeed duty, of perse- 
vering, so long as there is the slightest shadow of hope, in our en- 
deavours to save the patient. 

The causes of chronic laryngitis are not always appreciable. 
Sometimes the disease originates under the influence of atmosphe- 
rical changes. In such cases we find persons contract a slightly acute 
laryngitis, which soon passesinto a chronic state and never leaves them. 
The inspiration of irritating particles or gases which escape in vari- 
ous manufacturing processes; a prolonged mercurial course; foreign 
bodies in the larynx, occasionally give rise to it. Of the internal 
causes, unmeasured and protracted exercise of the voice is one of the 
most frequent and evident; as we see in the cases of preachers, pleaders 
at the bar, and other public speakers, and in actors and singers. Even 
here, obvious as is the exciting cause, we often see- so little propor- 
tion between its action and the occurrence of the disease, that we 
must look to other collateral causes, and perhaps still more to the 
predisposition of the parties affected. Belonging to this last, will 
be general debility from deficient exercise, depraved digestion and 
nutrition, excess in venereal indulgences, and the depressing pas- 
sions. The local predisposition may be found in a want of moderate 
exercise of the voice in the intervals between the formal and pro- 
fessional exercise and extraordinary strain on it, at stated times ; 
also, in continued irritation of dry hot air by a person habitually 
breathing such. Tobacco is a predisposing cause, both of general 
and local debility ; a disturber of the functions of the lungs, stomach, 



CAUSES— GENERAL AND LOCAL. 



663 



larynx, and pharynx, both by perverting the secretions of the 
mucous membrane lining these organs, and by at first exciting and 
afterwards depressing their nervous power. Whatever tends to at- 
tract fluids in excess to the larynx, and to derange the circulation 
in its mucous membrane, as well as indirectly to weaken the mus- 
cles of the larynx, which are those of the voice, by enfeebling in- 
nervation, must of course contribute to a morbid state of the larynx. 
The use of tobacco may bring on all these derangements of func- 
tion. But one would suppose from the obstinate perseverance in 
this filthy and eminently anti-social practice, that it placed the chances 
all on the side of health, rather than of that of disease and of a com- 
plication of unpleasant sensations more annoying to the sufferer than 
positive pain. The apparent exemption from deleterious effects in 
a few persons of a robust and phlegmatic habit of body, is no 
argument against the general rule. The same deceptive reasoning 
has been attempted to show the innocuousness of free spirituous and 
vinous potations in general. But how small the number of exempts 
out of the legions of those whose health and comfort and re- 
spectability have been ruined, and their lives abbreviated by such 
practices. Well have these privileged exemptsbeen called the Devil's 
decoys— seducers of the thoughtless crowd to their undoing. The use 
of ardent spirits is, particularly in conjunction with exposure to 
vicissitudes of weather, a powerful cause of this disease. 

Age and sex exert a great influence over the development of 
chronic laryngitis. Almost all the patients whose cases are re- 
corded by different writers were between twenty and fifty years 
of age ; the most of them between thirty and thirty-five. It appears, 
from the observations of Louis and Serres, that among individuals 
of the tubercular diathesis at least, the organic alterations in the 
larynx and trachea are twice as numerous among men as among 
women. Women are less subject to alterations of ihe organs of 
voice than men ; and children, whose constitution is very analo- 
gous to that of women, participate in this immunity. 

Mention has been made already of irritation and phlogosis of the 
fauces and pharynx being associated with similar states of the 
larynx. The disease of the latter is commonly in these cases, 
whether syphilitic or otherwise, consecutive to that of the former. 
In some cases of chronic gastritis, there is morbid redness and 
aphthae of the fauces and pharynx, which extend, by continuous syn> 
pathy, to the glottis and upper part of the larynx, and give rise to 
alteration in the voice, cough, expectoration of purulent mucus, &c. 
A restoration of the healthy state of the stomach, if accomplished 
in an early period of the disease, will bring about a removal of the 
laryngeal symptoms. In small-pox we have frequent instances of 
this extension of inflammation from the fauces and pharynx to the 
air passages, and the consequent changes in the voice and respira- 
tion already described among the symptoms of chronic laryngitis; 
with this difference, that in the secondary laryngitis from small- 
pox, the disease runs its course with a rapidity which brings it 
within the stage of acute disease. A slight irritation of any part of 



664 



CHRONIC LARYNGITIS. 



even the buccal mucous surface, by establishing an afflux towards 
the throat, will develop chronic laryngitis ; as, for example, a caries 
of one or more of the teeth. A celebrated opera singer, Mme. 
Mainville Fodor, the syren of the opera, who enraptured the in- 
habitants of Paris in my time of study there, is said to have lost her 
voice in this way. 

The treatment of laryngeal phthisis will vary w T ith the stage of 
the disease and the predominance of certain symptoms. In the 
first stage of the disease, marked by slight hoarseness, a feeling of 
heat and dryness in the throat, and imperfect expectoration or hawk- 
ing of mnco-serous matter, the remedies will be the same as for 
common catarrh. But if the inflammation does not readily yield 
to the simpler means, including an abstinence from all kinds of ex- 
citement, and if the hoarseness is increased, and accompanied by 
aphonia and the characteristic cough before described, more ener- 
getic and systematized measures are required. The first condition 
for restoration to health is entire rest of the vocal apparatus, as 
far at least as speaking above a whisper. Provided there be no effort 
made by the patient to render what he utters more distinct, speak- 
ing in a whisper is not attended with any evil in the opinion of 
Drs. Trousseau and Belloc : but even this in conversation with a 
stranger, when an effort at a certain pitch is made, is sometimes 
more fatiguing to the patient than his speaking aloud. The indul- 
gence of whispering is the more allowable, when we reflect on the 
extreme difficulty of keeping the patient silent for several months 
in succession. First among the class of antiphlogistic remedies, 
applicable to the more decidedly inflammatory or incipient stage 
of the disease, is blood-letting. The authors just named prefer 
greatly venesection to leeches, unless these are freely used. But 
if the disease have made progress, or the patient be enfeebled 
leeches are to be preferred ; in which case they should be applied 
on each side of the larynx and trachea, inside the sterno-mastoid 
muscles. The feeling of relief expressed by the patient after their 
use is often very great. Cups to the nape of the neck I have seen 
to be of marked benefit; although perhaps not equal to the other 
methods of drawing blood. If there is reason to believe that the 
disease has arisen from suppression of the menstrual or hemor- 
rhoidal discharge, or is greatly aggravated by such suppression, 
leeches ought to be applied in the former case to the thighs or the 
vulva, and in the latter to the anus. Emollients internally may 
soothe irritation without exerting any material influence over the 
disease ; but their external use, in the form of warm poultices to the 
neck, will be injurious by increasing the afflux of fluids to the throat. 
Coinciding with blood-letting, and a useful substitute for this latter, 
is tartar emetic, given at first to vomit, and afterwards with a view 
to its contra-stimulant effects, in such doses three and four times a 
day as the stomach will tolerate. In cases of sustained inflamma- 
tion, the vinous tincture of colchicum may be combined with 
the antimony, and occasionally, when the bowels are to be acted 
on, with Epsom salts. 



NARCOTICS— IODINE, ETC. 



665 



After the disease has been of some duration, revellents^ or counter- 
irritants, will be found to be among the most efficacious of our 
remedies. They are deemed more beneficial than blood-letting by 
MM. Trousseau and Belloc. Blisters are advantageous, but only 
when kept long discharging. They ought to be applied to the 
j nucha, because when placed in front they create too much pain 
! and irritation, especially in men with thick beards. Setons and the 
| potential cautery, applied to the anterior part of the neck, opposite 
! the crico-thyroid space, are, also, very useful. In milder forms of 
j the disease, the eruption produced by rubbing a liniment, composed 
of croton oil two drachms to an ounce of olive oil, at first twice 
l daily, will have a good effect. Next to this, and on the rising scale 
! of activity are the tartar emetic and the ammoniacal ointments 
rubbed, as in the former case* over the front and sides of the larynx 
and trachea, until an eruption is brought out by the former, and a 
I rubefaction or slight vesication by the latter. The antimonial fric- 
1 tions should be continued even after the pustules first appear, and 
| until they are confluent, and then renewed when the scab begins to 
fall; and so on at intervals of perhaps twice a month while the 
disease lasts, or as long as there is any evidence of relief being ob- 
tained by the practice. I have used iodine ointment with beneficial 
results. The writers already quoted direct, as part of a plan of 
counter-irritation, and we may suppose in cases in which the fric- 
I tions just specified have not been employed, a small piece of caustic 
potash to be applied once a week on either side of the larynx and 
trachea. In this way five or six cauterised spots are made to sup- 
I purate at the same time without the necessity of inserting peas to 
keep them open. Less confidence is to be placed in revulsives when 
applied at a distance from the diseased organ, unless in the case of 
suppressed discharge, as of sweat from the feet, haemorrhoids, &c» 
Narcotics are often of great use in assuaging the pain and cough 
in chronic laryngitis. Belladonna, stramonium, and hyosciamus 
have been severally recommended: the two former, in the shape of 
diluted or semi-fluid extracts, by friction to the anterior part of the 
neck. The salts of morphia, introduced by the endermic method, 
are, also, a valuable adjuvant to other measures. M. Cruveilhier, 
with a similar intention, directs the patient to smoke the leaves of 
stramonium, or of belladonna which had been boiled in a watery 
solution of opium, and afterwards dried. By calming the cough, 
and allaying and removing pain, these narcotic remedies remove 
causes of irritation and of flux to the larynx, and contribute to the 
cure. The use of the extract of stramonium in a two-grain pill 
j twice or thrice a day, will have a more uniform effect, as I have 
ascertained by repeated prescription of this remedy in asthma 
complicated with laryngeal affection. A mercurial course, that is, the 
action of mercury on the mucous secretors and capillary system — 
but always short of ptyalism, even in cases not syphilitic — I have 
found to be of manifest and permanent benefit ; particularly in per- 
sons of a sanguine temperament and a rather full habit of body or 
of active nutrition. In the scrofulous subjects we must use mer- 



57 



666 



CHRONIC LARYNGITIS. 



cury with more reserve, if at all; and where tubercular irritation is 
obvious the medicine must be carefully abstained from. Inthesecases 
the iodine — either a solution of the hydriodate of potass, three to five 
grains twice a day; orLugol's solution — iodine in water, in which 
the hydriodate has been previously dissolved, is applicable. In various 
chronic affections of the trachea and bronchial mucous membrane, 
as well as in the present disease, I have used the iodine with much 
benefit; and especially have had occasion to be pleased with its 
effects, when it has been combined with the compound syrup of 
sarsaparilla. In cases in which the secretion is copious and muco- 
purulent the balsam of copaiba has done good ; combined with 
sarsaparilla syrup, I prescribed the balsam on one occasion in 
what would be called tracheal phthisis, but in which the bronchia 
also were affected. The symptoms — consisting of expectoration, 
more than a quart in twenty-four hours, and accompanied by hectic 
and night sweats and a rapid pulse — disappeared under treatment of 
which this last combination w 7 as a leading part. The iodine had 
also been used in the manner already mentioned. 

When mercury is thought to be proper in chronic laryngitis, the 
preferable preparation is the blue mass in doses of five grains every 
night, with about the same quantity of extract of hyosciamus made 
up into pills. In the morning, if the bowels are not free, and the 
digestive apparatus disordered, some mild saline, or rhubarb and 
magnesia, will be used. This latter difficulty obviated, and a regu- 
lar and defined course determined on, the blue mass and hyosciamus 
are to be administered every night, and the syrup of sarsaparilla in 
the morning. The dose of this latter will be from half an ounce 
to two ounces, according as it is found to agree with the stomach 
and bowels by not oppressing the former nor purging the latter. I 
do not recommend this treatment as at all of a specific nature as 
far as regards this or any other disease, whatever may be thought 
of its action on particular tissues. In the morbid secretions which 
accompany chronic inflammations of the mucous tissue, and in 
ulcerations of this tissue in the respiratory, digestive, urinary, and 
genital organs, I do not hesitate to regard the blue mass, iodine, and 
the syrup of sarsaparilla, and occasionally the balsam of copaiba as 
medicines of undoubted efficacy; so far at least as I can be in- 
fluenced by my own experience, which in this particular entitles me 
to speak with confidence. Sulphurous mineral waters, though 
of secondary importance, are useful adjuvants to the mercurial and 
iodine course, especially in recent cases of the disease. 

But without the aid of Topical Means, the best devised general 
remedies are inefficient to the cure of chronic laryngitis, as they 
are of ulcerations and puriform discharges of the throat, nose, eyes, 
vagina, rectum, &c. These are laid down by MM. Trousseau 
and Belloc, as either emollient, detergent, or irritating ; so as in the 
latter case sometimes to destroy the morbid surface itself. " They 
are either pulverulent, liquid, gaseous, in vapour, or salts." These 
gentlemen think that they have ascertained " a method of bringing 
medications in form of vapour, powder, or liquid, in contact with the 
mucous membrane of the larynx, without interrupting respiration.'* 



TOPICAL MEANS. 



667 



Most frequently the vapour of water was employed, either simple or charged 
with emollient, balsamic, or aromatic substances. Sometimes the vapours were 
dry, as the smoke of tar, resins, hyosciamus, tobacco, poppy, &c. The moist 
vapours have also been charged with chlorine, iodine, hydro-sulphuric acid, and 
different essential oils, and applied with some effect to the mucous membrane of 
the air passages ; as shown by the experience of MM. Bertin, Gannal, Cottereau, Ri- 
chard, Sir C. Scudamore, and Drs. Murray, Trousseau and Belloc, most of which 
is detailed in my work on Baths and Mineral Waters. Various kinds of appa- 
ratus have been made for the purpose of inhaling these vapours ; but it is admitted, 
even by some of their inventors, that a simple teapot is as well adapted as the most 
complicated machine. The two last named gentlemen have also caused patients 
to inspire fumigations of cinnabar, sulphurous acid, &c, with various, but not 
recorded results. All inhalation, of whatever nature, is, however, liable to the ob- 
jection that the substance inhaled is not confined to the larynx, but comes in con- 
tact with the mucous membrane of the lungs which it may irritate. It is impos- 
sible to limit its action, and hence the necessity of restricting ourselves to the 
employment of emollient, aromatic, balsamic, and narcotic vapours, and such as 
cannot exercise any sinister influence on the lungs. 

The liquid medications are much more easily applied, and without 
risk of injuring the trachea and bronchia. Of these, some are irri- 
tating; others simply astringent. The former, muriatic acid, solu- 
tions of nitrate of silver, corrosive sublimate, sulphate of copper, 
and sub-nitrate of mercury, and the caustic solution of iodine as 
recommended by Lugol. The solution of the nitrate of silver 
would seem to be entitled to the greatest confidence on account of 
its rapid action, its relative harmlessness, and its known efficacy in 
so many external ulcerations and other lesions of tissue. The 
strength of the solution will vary from half a drachm to a drachm 
in two drachms of water. 

Vaiious methods have been devised for applying the caustic to the larynx. 
The simplest is the introduction of a small conical paper bent at its end, and 
which has been immersed in the solution, into the throat, and down into the 
larynx, the mouth of course being kept open during the time by the crooked 
handle of a spoon. A piece of whalebone answers the same purpose, and more 
conveniently reaches the part affected. When it is desired to cauterize the 
pharynx, the base of the tongue, and the top of the larynx at the same time, MM. 
Trousseau and Belloc take a piece of whalebone about a sixth of an inch in thick- 
ness, so that it will not bend too readily; this is heated at an inch or more from 
one end, and when softened sufficiently, it is bent at an angle of forty-five de- 
grees. To the end of this smaller portion a spherical piece of sponge is fastened, 
half an inch thick, which is moistened with a solution of nitrate of silver, and in- 
troduced in the following manner. The mouth open, and the tongue depressed 
as before, the sponge is passed through the isthmus of the fauces, which gives 
rise to an effort of deglutition and a consequent elevation of the larynx, and 
at this moment it is brought somewhat forward, and from the entrance of the 
oesophagus it now passes into the glottis, and by a little pressure against the latter 
the fluid is squeezed into the larynx. The cough which is produced at this 
time favours the introduction of the caustic. Vomiting is often excited by the 
operation. 

This plan, though not painful, is, according to its proposers, very disagreeable; 
and many patients refuse to submit to it a second time. These gentlemen have, 
in such cases, another means of effecting their object. To a small silver syringe, 
like that of Anel, a canula, at least five inches in length and curved at its free ex- 
tremity with a very small opening, is attached. The syringe is filled three-fourths 
with air, and one-fourth with a solution of nitrate of silver. The canula is then 
introduced into the posterior fauces, opposite the larynx ; and the piston being 
rapidly advanced, the liquid mixed with the air in the syringe falls in a fine 
shower on the superior part of the larynx and oesophagus. The patient is seized 
immediately with a convulsive cough and regurgitation, by which he throws off 



668 



CHRONIC LARYNGITIS. 



all the solution yet uncombined with the tissues. I have used, as more convenient, 
a piece of sponge sowed carefully to the end of a small sized gum-elastic catheter, 
with the rod in, and the end of which has the required curve given to it, so as 
to allow of a ready application to the opening of the larynx and borders of the 
epiglottis. The sponge is to be dipped in the solution as recommended before. 
The patient is to be made, directly afterwards, to gargle his throat with water 
acidulated with muriatic acid, or with salt water, which decomposes any of the 
remaining free solution in the pharynx. 

Another mode of employing caustic solutions mentioned by Dr. 
Stokes, is that of Mr. Cusack. A brush of lint, of the requisite 
size, is sewed on the end of the finger of a glove, which is then 
drawn on the index finger of the right hand. The patient should 
be made to gargle with warm water, and the lint, being dipped in 
the solution, can be at once, and with great facility, carried to any 
part of the pharynx, and even to the rima. 

It has been appropriately observed by the two French writers 
from whom I have so largely borrowed for the pathology and treat- 
ment of chronic laryngitis, that one must have practised these cau- 
terisations, or seen them performed, to have an idea of their harm- 
lessness and of the little pain which results. We are very much 
alarmed at a cautery, for it is exceedingly painful when applied to 
the skin or mucous opening, though scarcely felt in the pharynx, 
larynx, or the neck of the uterus. I know that the application of a 
strong solution of nitrate of silver to the epiglottis and rima glot- 
tidis has been followed by very little pain, and did not prevent the 
patient from sitting down to table and eating his meals as usual a 
short time afterwards. These gentlemen in their valuable work* 
adduce the histories of several cases in proof of the superior efficacy 
of this topical treatment over any other. It has succeeded after 
the other means had been tried in vain. 

Of the probable coexistence of angina pliaryngea with chronic laryngitis I 
have already spoken. Again, I would remind the practitioner of the importance 
of being aware of this conjunction, and, of course, of the necessity of examining 
carefully the lining of the fauces and pharynx, and of applying to it appropriate 
topical remedies ; emollients, if there be inflammation ; caustic solution, or pencil- 
ling it with caustic, if the affection be chronic, and manifest itself either by a re- 
laxed tissue, or by aphthous spots, or minute ulcerations. The portion of the mem- 
brane which in these cases more commonly requires to be treated in this way is 
that covering 1 he tonsils and the arch of the palate. For this purpose, we should 
touch, two or three times a week, the part just mentioned with a pencil of nitrate 
of silver, or a solution of the same, or a powder composed of six or eight grains of 
the salt to about a drachm of powdered sugar candy. A saturated solution of cor- 
rosive sublimate, or of sulphate of zinc, or of copper, will fulfil the same indi- 
cation. 

When chronic laryngitis has a syphilitic origin it will be removed 
by mercury, and at times under circumstances of the most dis- 
couraging nature, as where the patient had been reduced to the 
last degree of emaciation, with hectic fever and night sweats. But 
let us not forget that this result is not certain, even in old cases of 
syphilitic laryngitis ; and that mercury has in some of these aggra- 
vated all the symptoms. In these cases the ptisan of Feltz has 

* A Translation by J. A. Warder, M.D., of Cincinnati, of Doctors Trousseau and 
Belloc's Treatise, has been published in the American Medical Library. 



V 



TRACHEOTOMY. 669 

brought about a rapid cicatrization of the ulcers. — (Cruveilhier, Dic- 
tionn. de Med. et de Chir. Prat) The ptisan here referred to is 
made of a decoction of sarsaparilla 5 China root, and other vegetable 
matters of Jess strength, in which sulphuret of antimony has been 
previously put, and to which, subsequently, corrosive sublimate has 
been added. A neater and more pharmaceutical method is to 
direct a solution of the mercurial salt in water, to which some 
simple syrup and a little of Hoffman's anodyne have been added ; 
and afterwards, in the course of the day, the compound syrup, or a 
strong decoction of sarsaparilla. 

In the advanced stages of syphilis, in which the mucous mem- 
brane of the mouth and throat was the seat of extensive ulcerations, 
I have derived excellent results from the iodine preparations already 
mentioned, conjoined with the syrup of sarsaparilla, in cases, too, in 
which mercury had either failed to relieve or had aggravated the 
disease. 

There is, occasionally, an extreme state in this disease short of 
death, but which, if not relieved, ends in dissolution. I refer now 
to the imminent danger of suffocation in some cases ; a present 
remedy for which is tracheotomy. But before having recourse to 
this last trial of our art, we should have given effect to the following 
appropriate remarks and suggestions of Doctor Stokes. 

" In some cases spasmodic exacerbations occur, so severe as to threaten the life 
of the patient. These are more frequently met with in females, and demand a 
careful study. The suddenness and violence of attack, the absence of correspond- 
ing fever, and of tumefaction of the epiglottis, will in general suffice for the 
diagnosis. I have often seen cases in which ihe suffering was so severe, as that, 
at the instant, performance of tracheotomy was advised, yet in which the breath- 
ing was restored to its ordinary condition by the following simple treatment: the 
feet were plunged in warm water, the body enveloped in blankets, and a draught, 
consisting of camphor mixture, ammonia, valerian, ether and opium, — exhibited, 
and repeated according to circumstances. Under this treatment symptoms will 
rapidly subside, which from their character and continuance would seem to demand 
the knife; and I would advise that in all cases, previous to the performance of 
tracheotomy in chronic laryngitis, the question be carefully investigated, as to 
whether the urgent symptoms are the result of spasm or of organic obstruction. 
Let it never be forgotten, that, even where organic disease and thickening of the 
larynx exists, spasm may supervene, and be met by appropriate treatment. We 
are not much attached to the doctrine of diseases being necessarily separate, but 
experience tells us that nothing is more common than to see spasm following 
organic disease, or organic disease occurring after a purely nervous lesion. 

" In cases showing this liability to spasm, the belladonna or other anodyne 
plasters may be usefully employed." 

Tracheotomy ought not then to be performed except when the 
patient is threatened with suffocation, and all the promptly available 
medicinal means have been had recourse to. On these conditions, the 
operation having been performed, the physician now freed from 
the fear of seeing his patient die of asphyxia, may proceed to treat 
the affection of the larynx in a suitable manner ; and when the 
organ is capable of performing its functions, the canula can be 
withdrawn and the wound allowed to heal. Even should the dis- 
ease be of such a nature that the passage of air through the natural 
canal is afterwards impossible, the canula may remain for an in- 



670 



CHRONIC LARYNGITIS. 



definite period, and the life of the patient be lengthened. A case is 
given by MM. Trousseau and Belloc, of an individual wearing 
such an instrument made of silver for ten years. 

This would be the proper place for indicating the best preventive 
measures against so formidable, and, of late years, so frequent a 
disease, as chronic laryngitis. The immediate and exciting cause in 
most of those members of the different learned professions, law and divi- 
nity, who have been sufferers in this way is, no doubt, undue exercise 
of the voice : but as we meet with the disease in persons who are not 
exposed in this way, and since, as I have already remarked, there is 
often no proportion between the often repeated strain of the voice 
for a length of time and the frequency and violence of chronic 
laryngitis, we ought to look out for other causes, as well predisposing 
as exciting, beyond the one commonly regarded as the chief cause. 
We are, as yet, wanting in the requisite statistical data for a proper 
knowledge of the proportions of the members of different profes- 
sions and callings affected with the disease. So far as professional 
observation and popular belief may guide us in forming an opinion, 
clergymen are to be considered as' most liable to it. As far as they 
are concerned, then, our investigation should be directed to an in- 
quiry into, 1, the temperament which we may suppose would be most 
frequently met with in those whose early bias is to serious and reli- 
gious reflections ; 2, the bodily constitution and collegiate habits of 
students for the ministry ; 3, the kind of labour and exposure either 
voluntarily entered into by, or exacted from these young men after 
they have assumed the office and responsibilities of the ministry. It 
will be found, I believe, on a review of the facts under their several 
heads, that a youth of a nervous temperament and feeble constitu- 
tion, is exposed whilst at college, or when pursuing his theological 
studies elsewhere, to the enfeebling influences of deficient exercise; 
confinement in illy-ventilated halls and dormitories; study beyond 
measure, and at late hours in the night ; anxiety of mind, both as 
respects his preparation for the solemn part which he is destined 
to perform and his worldly success; habits of sensual indulgence, such 
as the use of tobacco and other means of enfeebling the nervous 
system. It is easy to see how badly such a person is prepared for 
the unremitting toil to which, partly from duty, partly from secta- 
rian rivalry, and in no small degree also from the urgent and often 
unreasonable calls, exactions in fact, by the inconsiderately 
zealous of his congregation, he is subjected, so soon as he accepts 
a call to a church. Preaching often on Sunday and not seldom 
during the week in close churches, and in the evening too, and in 
a pitch of voice beyond his natural one, would of itself bring 
on laryngeal disease in a person already feeble and unable to 
exert any organ much without inducing phlogosis and its con- 
sequences. But when to this cause we add exposure to frequent 
and sudden transitions from a dry and hot to a moist and 
cold air, as when leaving his own home to visit the sick, and still 
more to attend and officiate bare-headed at funerals, in the midst 
sometimes of a storm of wind and rain, or of snow ; and when he 
passes from a crowded church, in which he has been perspiring, to 



PROPHYLAXIS. 



671 



| the open air of a cold night in which he is chilled, we cease to 
! wonder that the preacher should suffer from diseases of the lungs 
and air passages, and especially of that part, the larynx, which has 
I been enfeebled by prolonged and violent exercise, and is, of course, 
! in consequence peculiarly predisposed to disease. 

The prophylaxis of chronic laryngitis should consist in an early 
! attention, on the part of the professional student, to all the agencies 
i counteracting to those which bring on the disease. These preven- 
i tive measures should be much exercise in the open air, a regular 
I training of the vocal apparatus by both methodical speech and even 
song, so as to accustom the voice to every variety of pitch and 
intonation, and to husband its strength, if it be naturally weak, by ac- 
! quiring the habit of distinct and expressive articulation and enuncia- 
tion. By uniting the two kinds of gymnastic exercise — that of the 
muscles of the body and limbs generally, and that of the muscles 
of the voice — the student will be both fitted to discharge his subse- 
1 quent duties and less liable to catarrhal and anginose affections. 
He will enter on the duties of his ministry with some bodily vigour, 
and with habits of exercise, which he will feel a pleasure, as it will be 
his duty, to continue. When prevented by inclement weather from 
taking exercise out of doors, he will have recourse to the use of the 
dumb bells and the parallel bars at home. Nor should he omit to 
keep his vocal organs in the proper tone during the week, in order 
I that he may without fatigue, certainly without injury, task them on 
Sundays. For this purpose he will not only read aloud but declaim, 
and vary his tone and inflections, so as to give himself a wide range 
of vocal utterance, and yet distinctness and power within this 
range. Deviation from healthy digestion, and particularly if as- 
sociated with uneasiness in any part of the throat, should be early at- 
tended to and corrected ; and a relaxation of the tissue lining the fauces 
and pharynx and investing the soft palate and tonsils, removed by 
astringents or even a slight cauterization in the manner already de- 
scribed. Among the hardening measures, is the use of the tepid bath, 
or sponging the surface of the body, and particularly the surface of 
the chest daily with cold salt and water. The throat should be 
well gargled at rising, and after every meal, and, at any rate, the 
whole neck washed in the morning with cold water. No ligature, 
or tight cravat, or stock should be worn — nothing, in fact, which 
exerts a compression on the neck, or invites more blood to the part. 

The above hints are applicable to the members of the bar, and to 
all public speakers who would strengthen their physical powers of 
utterance, and avoid disease of the vocal apparatus. 

As any sudden change of temperature of the air which is inhaled 
is prejudicial to the invalid suffering under chronic laryngitis, he is 
recommended when about to pass out from a warm room into the 
external air, to place a silk handkerchief, or some kind of network 
before his mouth and nostrils. There has lately been made in 
England an apparatus called "Jejfraxfs Respirator" which is 
preferable to a handkerchief, or any similar contrivance. It con- 
sists of a number of layers of delicate wire-net, secured on each 
side by morocco leather, and straps or strings so as to allow of its 



672 



CHRONIC LARYNGITIS. 



being tied to the back of the neck, whilst the person breathes 
through the wire-net, inhaling an air, which, by the time it has 
reached his mouth, and certainly his larynx, is of a suitably elevated 
temperature. I am acquainted with the case of a lady who, whilst 
suffering under catarrh, was kept awake half the night with a 
troublesome cough, which was speedily arrested, and she allowed to 
sleep undisturbed, after she had put on the respirator at her hus- 
band's suggestion. 

A more permanent amelioration is obtained by a change of cli- 
mate. With this view, a residence for a year or more in warmer 
latitudes, or sometimes during the winter months only, is recom- 
mended to patients with chronic laryngitis as well as to those 
with chronic bronchitis. Where circumstances prevent their ab- 
senting themselves from home, an artificial climate may be pro- 
cured by keeping up a uniform temperature and moisture in the 
house ; and the patient confining himself to it during the whole 
of the winter. But before having recourse to a change of climate, 
the patient should be freed from any inflammation of the air 
passages under which he may be labouring at the time ; for, 
without suitable precaution on this score, he will be more likely to 
be injured than benefited by leaving home, and exposed to the 
operation of causes in travelling which tend to aggravate the in- 
flammation. 

Another important consideration is the state of the digestive 
organs. There is hardly any morbid association more common 
than that of irritation of the bronchial and laryngo-bronchial mem- 
brane with a similar irritation of the stomach; especially after the 
middle period of life. In cases of this kind, it is well remarked by 
Sir James Clark ; M upon tracing the progress of the disease, we 
shall generally find that the bronchial affection, the * liability to 
catch cold,' the ' spring cough,' the troublesome morning phlegm, 
&c, did not occur till the patient had suffered for some time, often 
for years, from symptoms of disordered digestive organs. When this 
is the case we shall make little progress in the case of laryngeal 
and tracheal diseases until we have subdued the irritation of the 
digestive organs ; and the hopes of the successful issue of our 
treatment must, therefore, rest chiefly in the facility with which 
this yields to our remedial measures." 

This remark may be usefully extended to nearly all chronic dis- 
eases, over which the stomach, in its different conditions, displays 
so great and, at times, extraordinary an influence, as to induce 
those who are not patient and attentive in diagnosis, to attribute the 
constitutional disturbances caused by lesions in other organs, and 
notably in the lungs, heart, and even brain, to gastric origin. 



THE END. 



3 47 7 5 



I 



